This post was originally at Keynote at the Canadian Orthopaedic Manual and Fascial Therapy Division Conference on February 29, 2015 in beautiful Wawa, ON, Canada
This post was originally at Keynote at the Canadian Orthopaedic Manual and Fascial Therapy Division Conference on February 29, 2015 in beautiful Wawa, ON, Canada
Presentations Presenting at the APTEI 2014 Symposium: How faulty biomechanical reasoning may increase pain and disability.
Medbridge Health Breakouts: Where does Biomechanics Fit?
1. with strengthandconditioningresearch.com on Pain and Injury
1. Form, Footwear and Footstrike: Implications for running mechanics and injury. A very rough ebook from a lecture on the same topic
What is it?
A 4 session program to improve your running and decrease your chance of injury.
What is it composed of?
Is it covered by insurance?
Yes. I am both a physiotherapist and chiropractor. Each session can be billed separately and our rates are well within the normal fees charged for regular physiotherapy sessions
$400.00 for the initial 1 hour session plus 3 follow up sessions.
The timeframe is surprisingly flexible. Some people need a follow up session within a week of the initial evaluation. Others might need a follow-up session within 3 weeks. Having this flexible time frame allows us to tailor the program to your needs.
Can I work with my existing coach or personal trainer?
Absolutely. In fact, this is encouraged. I regularly work with running or triathlon coaches to create safer and better training programs. If you already work with a personal trainer we can speak with your trainer about encorporating the running performance program into your existing exercise sessions.
I am physiotherapist and chiropractor with a MSc in Exercise/Spine Biomechanics. I have published more than 20 peer-reviewed academic papers on exercise science and injury. I regular work with runners and multisport athletes from beginner's to Olympic athletes. I currently write injury prevention articles for Triathlon Canada. I am also an instructor with therunningclinic.ca - Canada's, if not the World's, leading course on the prevention and treatment of running injuries. Last, I am the clinical director of Medcan's Run Well 3D Kinematic Analysis Program for Running Injuries.
Clinical Decision Making in Running Form Interventions Initially written for Medbridge Education
The purpose of this article is to highlight the clinical decision making process during kinematic running analyses - focusing on evaluating the kinematic risk factors for running injury and not kinetics.
Both predictive and correlational research attempts to identify kinematic variables that are associated with an individual’s future or current injury. Many of those being:
-higher levels of pronation or pronation velocity
-increased tibial internal rotation
-increased knee abduction
-increased hip abduction or hip internal rotation
All of the above variables have been either documented as being elevated in runners with injury (correlated) or have been found to be precede the onset of injury (longitudinal research). As with most human function nothing is that straightforward though. To confuse us, all of the above factors have also been shown to have NO relationship to injury in other studies. We now have this dueling evidence base where it is very easy to cherry pick research supporting our ideas.
Pain and injury are multifactorial – simply suggesting that an injury is due to altered kinematics ignores the wealth of research highlighting the many variables that influence the pain experience. Thus, our clinical decision making is never as simple as finding a “flaw” and assuming that that is the driver of the injury. So how can we view these “flaws”?
Kinematic flaws and how we interpret them can be divided into three categories:
Injury is the failure to adapt stress
To determine the significance of a kinematic flaw a few assumptions regarding the nature of injury and pain are necessary. These are naturally open to debate. First, injury and pain should not be conflated. Runner’s can have tissue anomalies that many might view as pain (e.g knee OA, hip labral tears) and have no pain. They can also have pain with no evidence of disruption in connective tissue. Pain can be viewed as the brain’s response to the perception of a threat. With many factors (cognitions, past experiences, expectations, emotions) influencing the brain’s decision to output pain – nociception created by mechanical deformation of nervous tissue being just one.
With runner’s all of these factors can be viewed as stressors inputted into the system. An ideally adapting system (at least for those who want to run pain free) would be one where the brain does not output pain. Pain occurs when some immeasurable threshold is reached where the brain perceives a sufficient enough threat to output pain. An injury can be viewed as the body’s failure to adapt to the imposed loads that exceed the threshold for positive tissue adaptability. It is assumed that both the body and brain have the ability to positively adapt to imposed demands or loads. It assumes with appropriate and graded loading that both our connective tissue strength and our pain thresholds can be improved. Injury-free and pain-free running require us to stay below these thresholds.
How kinematics might contribute to pain
Altered kinematics may either create an initial noxious event leading to nociception, may contribute to nociception by continuing to sensitize nervous tissue or may even indicate a movement habit that a runner has fallen into and nociception itself does not need to be present. This habit of movement may even, to quote Lorimer Moseley, “facilitate protective neurotags”. What might initially have been a movement flaw that helped the system (e.g a defense) has now become associated with pain that has no further value. Our conundrum as clinicians is not determining whether the altered kinematic is cause or consequence of pain but rather determining if there is value in trying to address it.
How and when to address Kinematic Flaws
After we perform a running analysis we might find a number of kinematic variables that might be related to injury. The flaws we see pose two questions:
Going back to the assumption that injury or pain may occur when the demands on the body exceed its ability to adapt can we suggest that the kinematics measured might load the area of injury to such an extent that mechanical pain would occur? If a patient presents with medial leg pain, appears to pronate a great deal and the speed of that pronation appears elevated we might be able to suggest that those variables relate to the pain as biomechanical link of increased tissue strain can be made. This idea can be bolstered with post-hoc reasoning if simple interventions that might address the flaw (e.g taping an arch, running with a wider step width) positively change the pain experience. This thinking would be bolstered by some research that supports this link. But wait you naturally scream at me, there is lot of research suggesting pronation has no relevance to injury. This is absolutely true and leads us to a second question.
Rather than increased pronation and increased pronation velocity being interpreted as a defect we might argue it is merely a red herring. We see this in a number of elite runners with massive amounts of pronation and massive amounts of mileage and speed. Yet they have no pain. What factors might mitigate the proposed risk of having this assumed kinematic flaw? Could those with what appears to be a running kinematic flaw have adapted to this ‘flaw” over time? Have they progressed their mileage slowly over years? In some instances, flaws aren’t flaws. The runner is fully adapted to that gait style.
On the other hand, a novice runner may exhibit running mechanics sometimes associated with injury. She may be able to run pain free for awhile until suddenly pain develops with no change in her training. There has been no change in the loading placed on nervous tissue yet pain is experienced. A possibility exists here that the sensitivity of her system was changed. Thus her threshold for pain or injury was decreased. Since multiple factors influence this sensitivity it is important to attempt to address those factors. One such intervention would be to address the mechanics of her gait.
Strategies to address Kinematic Flaws and Pain
What’s great with treating running injuries is that we don’t always need to change the kinematic flaw. We have a number of studies showing that gait retraining can change both pain and running kinematics but we also have research suggesting that interventions can result in changes in pain with no changes in kinematics. In the latter instance, we can use the altered kinematics as a starting point in creating our therapeutic interaction.
At it’s most basic, treatment is merely the modification and judicious application of stress. The following two-step and not mutually exclusive approach can be used:
Desensitize and Unload
Much of what a manual therapist does would fit into this category. Again a multifactorial approach may be necessary. Interventions may be pain physiology education, education about tissue and nervous system adaptability, taping, temporary orthotic use, gait retraining, manual therapy, movement therapies and alterations in training loads.
Increase tolerance to stress
I believe most runners can keep running. In fact, they need this stressor to adapt. If we teach runners the importance of the adaptability of their system then they will understand the importance of a graded return to activity. Gait retraining would also fall into this category but it should be remember that gait modifications primarily redistribute forces during running. Thus a slow return to running with a new style is advised to again allow for the adaptation to the different stress. Last, we can use kinematics as a window into prescribing capacity or motor control exercises. Resistance training can be justified in running injury treatment both as a pain modulator and under the idea that a tissue’s response to loading can be improved – increasing injury threshold.
A future post will elaborate on the clinical decision making of these interventions. A helpful course on understanding running biomechanics and injury can be seen in this link.
We don’t know the ideal way to run and by extension we don’t know what are true kinematic flaws in running. We know that pain and injury are multifactorial and taking this big picture view of rehabilitation is helpful. Identifying what may be kinematic flaws can still provide a window into interacting with a patient. Addressing kinematic flaws, along with a runner’s clinical presentation, through a multimodal approach (e.g. desensitization, education, gait retraining, exercise selection, activity modification) is a comprehensive approach that recognizes clinical uncertainty.
Purpose: To review some of the data on ground reaction forces during running, the significance of this physical loading and how loading can be modified. WARNING: this post is massive. It is meant as a working and evolving repository of much of the research on this topic. It is a compilation that I would like to update as more work is added. I use a post like this as a living reference library so I don't have to search through an entire article to get the gist of it. It is not meant to win a writing award. Skip to the bottom for a summary.
What is in this post
1. Ground reaction forces (GRFs) overview
2. Relationship between GRFs and Injury
3. Modifying loading with step rate
4. Modifying loading with foot strike style
5. Modifying loading with shoe wear or going barefoot.
What are ground reaction forces and impact loading?
When the foot strikes the ground during running the ground produces a force back against the foot. The force can be broken into three directional vectors:
2. Forward - Backwards (e.g. "braking" and then "push off")
3. Side to Side.
Most of the research has focused on the Vertical loading so I will too. Vertical loading looks like this:
The first peak in force is termed the impact peak and results from the collision of the foot with the ground. We can also look at how quickly this force rises and when that peak occurs. This is called the rate of loading.
The second peak is called the active peak. It corresponds to the point when the energy absorption has stopped (the center of mass is at its lowest) and when we start to "push" off against the ground.
The relationship is contentious. It is simple to assume that less load or less stress on the body leads to a reduction in injury risk. But this does not always pan out. The human body has the ability to adapt and the variability across runners' ability to adapt is huge. Simply, we don't know how much load is bad for an individual person. You can even argue that loading is good in that this is what stimulates an adaptation in the runner (e.g. stronger bones, stronger soft tissue, a better nervous system?). What the cutoff is between good loading leading to adaptation and too much loading leading to injury is our Holy Grail of Injury Prevention. The concept of loading and loading rate on injury in runners could be a long post itself - I will just link to some articles below and briefly touch on this area.
There is some suggestion that the rate of impact loading is related to stress fractures in runners. See this post here and the abstract here. We also have some suggestion that decreasing peak loading can influence stress fracture risk (abstract here and here)
We also have some great research by Dr Irene Davis linking higher impact velocity (e.g rate of loading) with stress fractures (link here). Dr. Davis has also published case series showing changes in loading rates with feedback during running (abstract here).
Some links to follow for more information on this.
In the following sections we will take a look at three methods that are used to change loading during foot strike:
In an upcoming post I will review what other changes occur when we attempt to make these changes to impact loading. Changes don't exist in a vacuum. They could lead to changes in running economy, muscular activation or other unintended consequences that could affect performance and maybe injury risk.
The Bottom Line before the bottom
All three techniques are able to change impact loading and joint loading in some individuals but not in all individuals. What we see in the research is variability and this leads to conflicting results across studies. This is because there are other factors than the three above that influence the ground reaction force. For example, you can change to a midfoot or forefoot strike and still overstride (see a neat video and case on this here). The stiffness in our limbs can all influence impact. This is what happens to some extent with kinematic changes with aging. Older runners can have similar stride rates but still have greater impacts (for a brief review see here). But lets look at some research.
We can increase the number of steps we take while running. Heiderscheit et al (2011) did such a thing (for detailed review of the study look here and here). He increased step rate by 5 and 10%. This is some of what they found:
At both 5 and 10% increases in cadence
At a 10% increase in cadence only
A note on the ankle
There was no change in the amount of ankle energy absorption when increasing cadence yet a huge decrease in the amount of energy absorbed at the knee. This is most likely due to a lack of change in the ankle kinematics and how the foot struck the ground. I would guess that changing cadence was not enough to change the type of foot strike. If an individual went from a rearfoot to a mid or forefoot strike we would probably see more energy absorption at the ankle. Take home point, is that a lot variables can influence impact loading.
A note on the initial impact loading and loading rate
The authors found that reducing step length decreased the occurrences of that sharp initial bump in the ground reaction force. This is the impact transient and is what we most see in runners who heel strike - it is essentially the collision force with the ground. However, it was rarely seen (0-1 times in every 5 strides) only 56% of the time when increasing step rate by 10% (this lack of impact transient was seen 22% at preferred step length). So notice this is just a trend in some runners. If you notice with the study the authors did not calculate the average loading rate across all runners. This is how we typically compare loading rates across interventions. I would guess with the variability across the subjects we would not end up with a statistically significant change in loading rate. Presenting the data in this way shows us that sometimes we get a change in the impact transient just not always. As a refresher here is a lovely video of the loss of the impact transient with forefoot running.
Hobara (2012 -abstract here ) had athletes run at 2.5 meters per second and also modified step frequency (increasing huge amounts of 15 and 30%). They found decreases in:
The only issue with this study is how practical it is to have such a huge change in stride rates. It is great for a proof of principle but we should question whether we want to do this in terms of running economy and even injury risk (i.e. you are taking a lot more strides thus increasing repetitions).
...and the other side of things (nothing is ever that simple)
But, these findings were mildly contrasted with another neat study that looked at changing a number of things (step rate, foot contact style and type of shoe) and the loading response. Giandolini (2012)found the following when increasing cadence 10%:
These authors looked at the group average for changes in rate of impact loading. They don't show their raw data so it is possible that there may have been some individuals who decreased their rate of impact loading and perhaps lost the impact transient during initial foot strike. This would be consistent with the Heiderscheit study.
In this comprehensive study, these authors were also able to change a number of loading and kinematic variables with other interventions. They did two other things - put runners in a racing shoe (versus a big bulky cushioned shoe) and had the runners switch from a rear foot strike to a mid foot strike. They also combined all three changes (COMBI). So why don't we take a look at this neat-o study along with other relevant studies that look at changing footstrike style.
The research suggesting changing foot strike influences loading variables
This simple change provided some pretty drastic results. Giandollini et al (2012) found:
You can see a video version of this response in the video above from Dr. Lieberman.
...again it is never that simple. Similar research has found different conclusions
Laughton, Davis and Hamill (2003) investigated fifteen habitually rearfoot strike runners and then converted them to a forefoot strike pattern in a single session. The authors found:
some other findings:
WHOA...this is very conflicting. Sure is. It again stresses that changing a single variable is not sufficient to change other variables. Changing to this type of forefoot strike pattern either increased peak loading, no change in loading rates, increased braking forces and increased knee and leg stiffness. We don't know if stride rate changes but the increased anterior-posterior forces suggest that the forefoot striking may have been related to overstriding. Last, in this particular study the forefoot strikers were not permitted to let their heels hit the ground. They essentially ran on their toes. The Giandollini suggests that converting to midfoot strike can be beneficial (in terms of impact and force variables) but there may be a correct way to do this. i.e. don't just run on your toes
Further research showing variable impact loading with changes in footstrike
Becker et al (2012) in an abstract presented at the ASB 2012 concluded that foot strike pattern does not predict loading rates during shod or barefoot running. With a subject population of 11 (this study was reported as ongoing so it looks like it may be more robust in the future). The authors measured vertical impact loading rate and strike pattern in the runners when they ran either shod or barefoot. What they were able to evaluate was how footstrike pattern related to VILR in quite a novel way. The participants were not told to attempt to change their foot strike pattern. Rather, they had people either run with their shoes or in barefoot and measured their footstrike pattern with something called a Strike Index while also measuring their VILR. With these two measures in hand they determined how foot strike pattern related to VILR because some people would naturally change from a rearfoot pattern while shod to a forefoot pattern while barefoot. So, there were few permutations on what could happen. Here is a sample of what I see as relevant and check out the chart below for all the details.
Lets look at those instances where people RFS while shod but ended up switching to a forefoot strike while barefoot:
The flow chart below shows what happens to the vertical loading rate to individual runners when they either change to a midfoot/forefoot strike (MFS/FFS) while barefoot or remain heel striking (RFS)
The bottom line from this study is that a mere shift to a MFS/FFS is not sufficient to get less VILR. This study is also confounded with the shift from the shod to barefoot but it again suggests that is not a sufficient condition to automatically assume you will get less loading rates. Big limitation: there was no training or time allowed for habituation. This is short term study and may not reflect what happens with motor learning over time.
I will cut right to the chase here. Changing your shoes is not always enough to get changes in loading variables. Big bulky shoes are knocked under the assumption that the ass of the shoe gets in the way and forces runners to land on their heels and overstride. We assume that replacing these shoes with lighter shoes (and less of a heel to toe drop) will lead to a change in how we run to avoid heel striking (due to pain) and overstriding. Lets look at the research on what happens in different shoes.
Possible Study Outcome #1: Traditional versus minimal shoes lead to variable changes in loading
Goss et al (2012) Accuracy of self-reported footstrike patterns and loading rates associated with traditional and minimalist running shoes (ASB 2012).
These authors looked at 57 runners who ran in either traditional running shoes (n=22) or minimalist running shoes (n=35). There were no details on what these minimal shoes were. The authors measured ground reaction force and were classified into either a rearfoot or forefoot runner. This gave three categories of people: 1. rearfoot striker with traditional shoes (TSR) 2. Midfoot striker in minimal shoes (MSA) and 3. rearfoot striker in minimalist shoes (MSR). Before doing the assessment they also asked the runners how they thought they struck the ground. Here is what they found:
Possible Study Outcome #2: Shoes versus barefoot lead to increases in joint loading
Kerrigan et al (2009) looked at the influence of running shoes on lower extremity joint torques in standard running shoes and barefoot (n=68). They found increases in the following joint torques when going from barefoot to shod:
In terms of ground reaction forces there were increases with shod running in:
with a decrease in the minimum anterior to posterior GRF
Stride length was found to increase from 2.15 meters (barefoot) to 2.29 meters (shod) although the authors suggested that this accounted for only a small percentage of the changes in joint torques.
Possible Study Outcome #3: Minimal shoes lead to increases in joint loading
Logan et al (2012 - ASB Abstracts here) GROUND REACTION FORCES BETWEEN RUNNING SHOES, RACING FLATS AND DISTANCE SPIKES IN RUNNERS
The authors compared the three different shoes and aspects of the ground reaction force (Impact peak (BW), loading rate (BW/s), peak braking and propulsive force (BW), peak vertical force (BW), stance time (s), and vertical stiffness (BW/m)) in runners (n=18) who were all habitual rearfoot strikers. Further, these runners were college track athletes running between 5.67 -6.7 meters/s. This is fast considering that running around a 5 meter/second pace will have you run 5 km in 16:40. They found:
Impact peak and vertical stiffness significantly increased between running shoes and spikes. Differences between stance time and loading rate approached significance with trainers being lower
This again is interesting. I don't know if these runners changed their foot strike with any of the shoes but it reiterates that changing shoes to a more minimal shoe is enough to positively lower loading variables. In this case it increased them. I would assume that these runners were still heel strikers despite the change in shoe. This group shows that you can have less of an impact peak, less vertical stiffness and a trend to having less loading rate with a trainer than with more minimal shoes. Take home point here is that our movement patterns involve motor learning...motor learning involves effort, time and conscious attempt to change how we move.
Possible Outcome #4: Shoe differences are minimal but going barefoot decreases loading variables.
...and now a contrary view Hamill et al (2011 with a detailed review here) in a study titled "Impact characteristics in shod and barefoot running". The authors compared barefoot running with running shod in three different shoes of different sole thickness (1. A shoe with a 4mm heel and 0 mm forefoot; 2. a shoe with 12mm heel and 8mm forefoot and 3. a shoe with a 20mm heel and 16mm forefoot). The authors looked at the immediate response with these different shoes. Again, there was no training or attempts repatterning a gait stride. Their results in a nutshell were:
Possible Outcome #5: Minimal shoes show no effect on impact loading
The Giandollini (2012) study compared standard cushion shoes with a racing shoe (important note: the racing had a large heel to toe drop of 10.8 mm - thus some may not call this a minimal shoe despite there being less mass). The authors trained the participants and had them run at the same speed with the two different shoes on. The authors found no difference in loading rate, time to peak vertical load and peak vertical loading. The authors suggest that individuals continue to use a heelstrike style of running and that the minimal shoe did not coerce the runner into changing their running style. What I find interesting is that even though the racing shoe is much lighter with less cushioning there are no adverse consequences to running with a similar style compared with the normal cushioned shoe. Below is a nice graphic representation of all of Giandolinni's interventions on the vertical ground reaction force.
Brief Summary of changing gait variables to influence impact loading
All methods can influence of impact and joint loading but not consistently.
Increasing step rate can decrease joint loading but does not always lead to a reduction in the impact transient or rate of impact loading
Changing to a midfoot strike does have evidence to change impact loading variables but again in some individuals we won't see any change
Changing to a midfoot strike may also result in other factors that increase the strain on the tibia (link here for a start to this interesting idea). We can't say with certainty that everyone should be doing this change. A follow up post must and will address this area.
Changing your shoes to lighter weight or minimal shoes also has variable effects. Most importantly, instances can exist where your loading can increase when going to lightweight, minimal shoes. Most likely due to maintaining the running style that you have adopted when running in your previous cushioned trainers
The Giandollini et al (2012) study is really quite lovely. They look at as many variables and interventions that you can reasonable look at. They show how many techniques of what we think might change impact don't consistently change impact and they also provide insight into the "whys" of this. I also like their conclusion (probably because it agrees with something I wrote last year on barefoot running and foot strike style and I need reinforcement :) ) where they write:
our results show that running "barefoot-like", i.e. with a midfoot strike pattern may be an effective solution to reduce the magnitude of impact, as quantified through the loading rate
Purpose: Demonstrate a case of an altered nerve tension in a runner that may be exacerbated by their running technique. Case Details
Female, late twenties, competitive runner (sub 20 minute 5km, 1:30 half marathon, 3:15 full marathon)
- 2 year history of left lateral lower leg pain that comes on with running
- begins around 20-30 minutes into a run and often feels like she can't control her leg with a sense of numbness (like she might fall)
- but no obvious swelling, shininess or pain in the anterior compartment during these bouts
Select Physical Exam Findings
- neuro screen, strength, ROM, single leg squatting, usual "functional tests" are all normal
- no significant pain on palpation of entire lower leg
- positive Slump test with a bias toward the superficial peroneal nerve. This also occurs during a straight leg raise test with a superficial peroneal nerve bias. The sensation felt is the same as that felt during running. The video below is essentially the test movement (except change the ankle dorsiflexion for plantar flexion/inversion)
In the video below I noticed two things that may be significant. This runner is predominantly a forefoot striker even at slow speeds. Quite rare. She essentially reaches out for the ground with her forefoot. If you notice her knee it is actually quite extended just before foot strike. This is not normal. See a kinematic review of running here. There is usually quite a bit of knee bend before landing and of course on impact. Simply, this runner overstrides with a forefoot strike. She does this both in shoes and in socks. This position is similar to the Straight Leg Raise test with a peroneal nerve bias and it may be contributing to the "funny" feeling in the leg. A review of running biomechanics with video can be seen here.
I can't rule out exertional compartment syndrome but I also can't confirm that with ease as the test would take over 3 months to get here in Toronto. And Andy Franklyn-Miller (UK sports doc with a great deal of experience studying this type of thing - website here) would suggest that this test is even questionable for this condition and we might even want to question the condition itself. So I keep the exertional compartment idea in my head and look at other possibilities.
Why I question the compartment syndrome is the positive response I get when I stress the superficial peroneal nerve with neurodynamic testing. I don't believe that this is a classic response for exertional compartment syndrome suggesting to me that we have an altered neurodynamic on our hands.
- explain pain, always explain pain
- at home - every hour, 5-6 nerve sliders for the peroneal nerve (video below but don't dorsiflex the foot)
- running changes: this is tough but our runner is working on a midfoot strike and is trying to cue the idea of landing behind her (this is impossible but it can get the idea across).
- I also treat the "container" of the nerve. I do gentle soft tissue work (I used to be an A.R.T guy but I am much gentler now and don't believe the theory they propose) along the entire sciatic nerve. I think that I am really the nervous system and ultimately influence the muscle and the peripheral nerves with my manual therapy. You can explain this treatment anyway you like. I choose a neural based explanation rather than thinking that I am digging out adhesions.
- I believe runners should be strong. And not just runner strong - athlete strong. This runner has had previous high hamstring tendinopathy/tearing (or possibly sciatic nerve or all the little nerves back there irritation) so she is on a heavy resistance training program for everything. I don't emphasize anything - I just train for balance, capacity and variety. She gets exercises like one leg deadlifts, deadlifts, squats with bands, hip thrusts, hip airplanes, bridges, clamshells, one leg squats, one leg lateral wall squats, nordic hamstrings, push ups, suitcase carries etc. Click here for a "hamstring" injury for runners sample program for videos
Is she better?
Sorry, don't know yet. Just started. Any ideas please let me know. I can say that after I gently treat the region around the sciatic, tibial, peroneal nerve we are able to decrease the sensitivity associated with the SLR testing. This is a good sign. I am cautiously optimistic.
Audience: Runners and therapistsPurpose: To summarize the biomechanics of running strike pattern and shod conditions
I feel like in the blogosphere and the popular running media that there is a love affair with all things barefoot. Barefoot running is associated with forefoot striking and there appears to be changes in the biomechanics associated with alteration in running form when compared with heel striking. However, the research gets presented as if it is very neat in tidy when in fact it is quite murky. This post is a work in progress. It attempts to summarize some of the work comparing barefoot running with shod running and the work that compares forefoot striking and rearfoot striking while running in shoes. I hope that I have conveyed that the results are quite conflicting. Hence, what a pain it was to try to summarize this work.
This post will be updated consistently. Please view it as a work in progress.
-there is a trend to shift from rearfoot striking to landing more on the midfoot or forefoot
-an increase in step frequency (e.g. more steps per minute)
-a decrease in step length (Divert et al 2008, Squadrone 2009)
-the foot is more plantar flexed (i.e. the toes point down at contact) and there is a greater degree of ankle motion (Pohl and Buckley 2007, Lieberman et al 2010)
-a decrease in the amount of peak pronation or calcaneal eversion (Morley et al 2010) which is most evident in runners who pronate a great deal. Going barefoot decreases peak eversion from 10.3 degrees to 6.7 degrees in moderate pronators and from 14.8 degrees to 9.2 degrees in super pronators.
-the time it takes to get to maximal calcaneal eversion decreases in barefoot
-total eversion distance is increased with barefoot running. Even though there is less pronation the foot starts in a greater degree of inversion when barefoot. Therefore, the heel travels a greater distance when striking the ground to reach maximal eversion/pronation.
Force or Impact changes
-a decrease or complete reduction in the impact peak (aka. impact transient) when the foot strikes the ground but the push off peak is unchanged. A shod heel strike vertical ground reaction force can be seen in this video from Dr. Lieberman:
In the following graph notice how the first "bump" is lower in the barefoot and forefoot condition when compared with the rear foot shod condition (Divert 2008).
Ummm, is the initial impact transient eliminated with Barefoot running?
The initial impact transient is not always eliminated with barefoot running. While, other researchers (Lieberman 2010) show that the initial impact peak or impact transient is completely washed out rather than just decreased this is not always seen. Dr Lieberman's work is fantastic and his argument is beautifully laid out. His website is here (http://www.barefootrunning.fas.harvard.edu/4BiomechanicsofFootStrike.html)
He also provides this video showing the impact transient loss when running barefoot and forefoot striking.
In the study by Divert (2008) three out of the 12 subjects continued to demonstrate an impact transient. This difference may be due to the fact that other studies investigate youths who have always run barefoot while in the above graph (from Divert 2008) the subjects were just learning to run barefoot and may have not run a sufficient number of steps for the body to adapt and modify its kinematics. In effect, the sample used in the above study may have not had enough time to learn how to run barefoot to eliminate that impact peak.
Nonetheless, below is a graphic by Dr. Lieberman showing the loss of the impact transient with barefoot forefoot striking
In contrast to Dr. Lieberman's work, other studies have also looked at habitually barefoot runners and have NOT found a complete loss of the impact peak, albeit a reduction was found when running barefoot or in Vibrams versus a standard shoe. Squadrone (2009) compared barefoot, shod and Vibram wearing runners in athletes who have had extensive experience running barefoot (3 of them having completed a marathon barefoot). In the following graph notice how the impact transient is still greatest with shoes, decreases with barefoot and is most modified with Vibrams (VF). Most importantly, notice how the impact transient still exists. These authors did not calculate the slope of this impact transient so it can not be directly compared with the work of Lieberman et al (2010).
How can this impact transient still exist in minimalist or barefoot runners?
One difference between Lieberman's group and Squadrone's group may be the degree of plantar flexion in the ankle that occurs at footstrike in both groups. In Squadrone's group the ankle is at 94 degrees - this means about 4 degrees of plantar flexion. In Lieberman's group the plantar flexion in habitually barefoot Kenyan youths is around 14 degrees.
This is an important point which leads to a main thesis of this article. It implies that barefoot or minimalist running alone is NOT A SUFFICIENT condition to obliterate your impact transient during foot strike. In fact, if you run barefoot in a heel to toe fashion you will see an increase in the impact transient. This was seen in the work by De Clercq (2000) who compared barefoot versus shod but made everybody still run with a heel strike. This was found a decade later by Dr Lieberman. De Clerq found this:
Not to be too confusing but the above authors also measured foot dorsiflexion at impact and found an ankle angle of around 94 degrees (4 degrees of plantarflexion) with a sole angle around 12 degrees (I believe the sole angle is the angle of the entire foot relative to the flat ground). Zero degrees would be flat while 12 degrees means the toes are pointing up relative to the ground (this is my interpretation, it was not explained in the article). This ankle angle in the barefoot condition is similar to the Squadrone's study of 94 degrees yet we see an impact transient as well as a greater rate of force development in the barefoot condition. My interpretation here is that while the ankle was slightly plantarflexed the heel still came down first (i.e. the sole angle was still pointing up). I don't know what the sole angle was in the Squadrone study but it certainly might help explain the difference between studies.
Bottom line about barefoot.
Obviously barefoot running is no panacea for eliminating an impact transient. Additionally, there are other factors associated with barefoot running (e.g Kinematic variables: stride rate, stride length, ankle range of dorsiflexion, range of pronation) that may influence many of the kinetic variables (e.g. impact transient, ground reaction forces). And most importantly how does it relate to injury and performance?
So lets look at these other variables. Very simply, barefoot running seems to shift someone from being a Heel striker to being a forefoot striker. A small amount of research has investigated the differences while running in shoes with a rearfoot versus a forefoot strike pattern.
They sure can, please read more. Dr Irene Davis has been involved in much of this research but there is surprisingly little published. Dr. Davis' published work often cites her unpublished lab findings when comparing a Rearfoot strike (RFS) with a forefoot strike (FFS). Some of what I cite below will refer to Dr. Davis' statements (Williams et al 2000 or Laughton et al 2003) in her introduction or discussion instead of her actual data (which I can not get a hold of).
- forefoot strikers have increased calcaneal eversion excursions and eversion velocity (McClay and Manal 1995a/b) but end up with less maximal calcaneal eversion (aka pronation)
- the foot lands with greater ankle plantar flexion and is in greater inversion at foot strike in the Forefoot strike condition.
--increased knee internal rotation velocity in Forefoot strike conditions (Williams et al 2000)
Changes in Leg Stiffness
-According to the work of Laughton et al (2003) forefoot strikers have greater leg stiffness in general but less ankle stiffness. They have less ankle stiffness because there is more time and range of motion for the ankle to bend. Essentially, there is more time for the ankle to spread out the joint torque during impact because the ankle moves a through a larger range with the forefoot strike (remember, the foot contacts the ground with the toes down in plantar flexion) (Laughton et al 2003). These authors also found that the knee does not flex as much in the forefoot strike condition as in the rearfoot strike conditions (30 degrees versus about 34 degrees) therefore there is greater overall leg stiffness.
-Conversely, according to the work of Lieberman et al (2010) forefoot strikers have greater leg compliance (defined as the drop in the body’s centre of mass relative to the vertical force during the period of impact) meaning there is also greater Knee flexion as well as ankle flexion when striking with the forefoot.
Inconsistent changes in Impact Force with forefoot strike
Dr Lieberman's website has an excellent video that shows modifications in the impact transient when striking with a forefoot in shoes. Unfortunately, this kinetic information is not accompanied with a great deal of kinematic information.
Dr Lieberman has shown the loss of the impact transient in the following video:
However despite this decrease in the impact transient documented in the video the one other study that investigated Shod running and changes in foot strike pattern show different results.
A review of Laughton et al (2003)
These authors compared rearfoot and forefoot strikers ground reaction forces and found the following:
-There is less peak tibial positive acceleration in the rearfoot strike condition
-The average peak vertical ground reaction force, the anteroposterior peak GRF (i.e. the braking force),and average anteroposterior GRF load rates were significantly greater for the FFS pattern than for the RFS pattern
-Average and instantaneous vertical GRF load rate (i.e. the impact transient), however, did not differ significantly between the FFS and RFS patterns.
-BUT...in the Laughton study the forefoot striking runners were different than your typical forefoot strikers. You might actually call the TOE runners because when their forefoot struck the ground they were not allowed to let their heel strike the ground. This is not what happens with barefoot/forefoot running. This may account for the differences in loading.
Is this getting CONFUSING?
What I take from this is that forefoot striking can certainly decrease the loading rates on the foot/shank to a similar extent as barefoot running. But again, it is not a SUFFICIENT condition. I would guess that it might even be possible to train yourself to run with a heelstrike but in such a manner that you decrease your impact transient. Work out of Dr. Davis' lab that gives feedback to individuals on their tibial shock shoes that people can learn to run softer and decrease the impact transient. In these studies (click here) no advice is given to forefoot strike and individuals wear neutral shoes. They are merely asked to run softer and are given feedback.
I don't have a definitive answer for why the Laughton study shows no change in the impact transient yet Lieberman's work shows a significant decrease in the loss of the impact transient. My hunch is that other kinematic variables may influence the loading through the foot. One explanation may be that if in the Laughton study there was no difference in the stride length when shifting to a forefoot strike from heel strike then this may account for the lack of a loss of the impact transient (couple this with the lack of the heel being allowed to lower to the ground - a type of impact absorption and this may explain our differences).
What is missing in this review
- research investigating whether individuals could wear standard running shoes yet still be trained to run in a manner that mimics all of the kinematics of barefoot, forefoot strike running.
-any research investigating the theory (I stress theory) that running in shoes influences plantar foot proprioception which in turn negatively influences running - this belief is very common and is always written about in a superficial manner. Yet there is not a lot of research investigating it. I will reserve an opinion.
-a full body kinetic analysis comparing all the different foot conditions of running.
-long term studies investigating changing stride mechanics on injury prevalence and running efficiency
-I purposefully left out the good research investigating the POSE technique
Clinical Relevance - What I tell my patients
I think it is too early to give barefoot running the gold medal and switch everyone to minimalist shoes but I am certainly open to the idea. Runners were still getting injured with minimalist shoes in the 1970s (see a pdf review here: Am J Sports Med-1978-James-40-50 running injury overview from 1978 surprisingly good we know nothing new)
Barefoot or forefoot strike running may be an excellent adjunct to the recreational runner as a training stimulus. It can be used as a form of strength training or rehabilitation.
No research has looked at the impact transients with runners who run much slower than what is studied in these papers. Most of these papers have the slowest runners running 5 minute kilometres (an 8 minute mile). The vast majority of your recreational runners do not run this pace. If you run at 25 minute 5 km you will probably be in the top 10% of a large race (for example, at the 2010 Goodlife Marathon 5 km a 25 minute result put you 178th out of 2721) and the top 15% if you keep that pace up for a marathon. So, do we want to be telling all our runners to covert to a forefoot strike, minimalist shoe or barefoot based on the research of relative elites? the only correct :) answer is -----I have no idea.
Good luck piecing this all together and stay tuned for more updates.
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(1):6-13.
Divert C, Mornieux G, Freychat P, Baly L, Mayer F, Belli A. Barefoot-shod running differences: shoe or mass effect? Int J Sports Med. 2008 Jun;29(6):512-8. Epub 2007 Nov 16.
Pohl MB, Buckley JG.Changes in foot and shank coupling due to alterations in foot strike pattern during running.Clin Biomech (Bristol, Avon). 2008 Mar;23(3):334-41. Epub 2007 Nov 19.
Morley JB, Decker LM, Dierks T, Blanke D, French JA, Stergiou N. Effects of varying amounts of pronation on the mediolateral ground reaction forces during barefoot versus shod running. J Appl Biomech. 2010 May;26(2):205-14.
Lieberman DE, Venkadesan M, Werbel WA, Daoud AI, D'Andrea S, Davis IS, Mang'eni RO, Pitsiladis Y.Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature. 2010 Jan 28;463(7280):531-5.
Carrie A. Laughton1, Irene McClay Davis2, and Joseph Hamill Effect of Strike Pattern and Orthotic Intervention on Tibial Shock During Running JOURNAL OF APPLIED BIOMECHANICS, 2003, 19, 153-168
Williams DS, McClay IS & Manal K: Lower extremity mechanics in runners with converted forefoot strike pattern. Journal of Applied Biomechanics, 16(2): 210-218, 2000.
McClay, I., & Manal, K. (1995a). Lower extremity kinematic comparisons between forefootand rearfoot strikers. In K.R. Williams (Ed.), Conference Proceedings: 19t Annual Meeting of the ASB, Stanford, CA (pp. 211-212). Davis, CA: UC–Davis.
McClay, I., & Manal, K. (1995b). Lower extremity kinetic comparisons between forefootand rearfoot strikers. In K.R. Williams (Ed.), Conference Proceedings: 19th Annual Meeting of the ASB, Stanford, CA (pp. 213-214). Davis, CA: UC–Davis.