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IntroductionOne of the primary topics for

requests for information by themedia from the American PodiatricMedical Association and the Ameri-can Academy of Podiatric SportsMedicine is barefoot running. Tobetter deal with the numerousmedia queries, APMA and AAPSMdeveloped a position statement onbarefoot running that concludes,“Currently, inconclusive scientificresearch has been conducted re-garding the benefits and/or risks ofbarefoot running.”1 As will benoted later, this statement is truebut does little to help those clini-cians unsure of how to best counseltheir patients.

What follows is a summary ofwhat has been learned about bare-foot running thus far and is an at-tempt to cut through the claims,both positive and negative, in order

to assist the clinician in advisingpatients.

Barefoot Running: The HypeBarefoot running is not new.

Besides the obvious ancient unshodancestors, barefoot running wasshowcased with the 1960 Olympicmarathon victory by Abebe Bikila,as well as world class performancesby Herb Elliot, Bruce Tulloh, andZola Budd over the ensuing years.Indeed, the author participated inweekly barefoot running sessions as

part of track practice in the late1960s. More recently, however,there is a significant interest inbarefoot running which appearsmotivated by claims of improvedperformance and reduced injuries.

The ClaimsIt seems much of the impetus

for the current excitement stemsfrom the current bestselling bookby Christopher McDougall, Born ToRun, A Hidden Tribe, Superathletesand the Greatest Race the World HasNever Seen2 that details the exploitsof the Tarahumara Indians of theCopper Canyon of Mexico. These

runners regularly cover ultra-marathon distances, either barefootor in simple sandals. McDougall ob-serves that the Tarahumara, despitetheir huge running mileage, do notappear to suffer from the high de-gree of running-related injuries thatthose in the civilized world do.Coupling this with an unchangedinjury rate, despite decades of tech-nological improvements in runningshoes with regard to motion con-trol and cushioning, he makes theclaim that shoes are the cause ofmany running-related injuries. Mc-Dougall and early work by re-searcher Steven Robbins in the1990s,3,4 claimed that shoes: 1) con-fine and limit foot motion whichresults in intrinsic musculaturewasting; 2) mask the proprioceptive

By David W. Jenkins, DPM

Continued on page 60

What should you tell patients when they ask?

Currently, inconclusive

scientific research has

been conducted

regarding the benefits

and/or risks of

barefoot running.

NOVEMBER/DECEMBER 2010 • PODIATRY MANAGEMENTwww.podiatrym.com 59

C U R R E N T T O P I C S I N S P O R T S P O D I A T R Y

Advising Your Patientsabout Barefoot Running

FIGURE 1: Barefoot runner

ioned foot will be subject to os-seous damage such as stress frac-ture, listed below are some of theother concerns.

1) Surface hazards such as glass,rocks, insects, and temperature ex-tremes

2) Contact with microorganismsand infectious agents

3) Runners with lack of protec-tive sensation

4) Runners who require motioncontrol shoes and/or orthotics

5) Increased impact at footstrike

6) Achilles and/or triceps suraeinjury from forefoot strike

The Evidence-ProThere is little doubt that bare-

foot runners have a distinctly dif-

ferent gait than shod runners. Re-duced impact with forefoot strikeappears to reduce collision forces.7-9

Numerous studies in the lab understatic (not running) conditions dodemonstrate improved propriocep-tive ability in those who are bare-foot and that improved foot posi-tion sense may assist in the ob-served gait changes responsible forreduced impact.10-12 Limited studiesdo support the idea that the bare-foot condition may strengthenplantar intrinsic, and this in turncan improve arch structure.13,14 Last-ly, there is evidence that those run-ning shod are less efficient with en-ergy utilization.15-17

The Evidence-ConThere is no evidence that bare-

foot running causes injuries such asstress fractures or Achilles tendoninjuries although clinical experi-ence would say otherwise—it could

interaction of the foot to theground; and 3) encourage an un-natural heel strike that increasesdamaging impact forces. Theseideas have been further echoed bypopular barefoot running web sitessuch as Running Barefoot and Bare-foot Ted’s Adventures. These sites arepacked with “how to” information,FAQs and links to studies that ap-pear to support the claims of bare-foot running advocates.5,6

The BenefitsBefore looking at the evidence,

what are the purported benefits?Though not necessarily a benefit,profound and undeniable differ-ences are observed in the gait of thebarefoot versus the shod runner,and these are said to be responsiblefor some of the stated advantages.Barefoot runners have a shorter andquicker stride and will experienceless overall ankle, knee, and hipmotion. The ankle will be plan-tarflexed and foot strike will bemid-foot or forefoot (Figure 1).Both flight and contact time will bereduced.7 Listed below are the mostnotable claims of barefoot runningadvocates.

1) Reduced collision (impact)forces

2) Improved proprioception3) Stronger plantar intrinsic

musculature4) Improved energy utilizationClaims 1-4 are then said to re-

sult in reduced injuries and betterperformance. An often-mentionedexample is that those with betterproprioception would surely experi-ence fewer ankle sprains. Addition-ally, the stronger plantar intrinsicsand absence of confining shoes aresaid to lessen the risk of foot defor-mities such as pes planus.

The Risks andContraindications

Nearly all of the downsides ofbarefoot running come anecdotallyfrom the healthcare provider com-munity fueled by numerousepisodes of patients who hobble inwith injuries sustained while bare-foot running. A number of theseclinicians consider barefoot run-ning silly and/or dangerous. Besidesthe major concern that an uncush-

be argued that most of theseepisodes were the result of inade-quate adaptation. Though it is un-deniable that surface hazards exist,there is really no evidence that theypose a risk to those running bare-foot. Interestingly, the barefootcondition is favorable to microor-ganisms and infectious agents.Those running barefoot are at nogreater risk for plantar verruca, areat less risk for tinea pedis, and areless likely to suffer a pseudomonasinfection as a result of a puncturewound.18-20 There are no studies toshow that those needing motioncontrol and/orthotics for diagnosedconditions will be at risk if under-taking barefoot running, but logicand clinical experience would sayotherwise. Evidence as well as com-mon sense is overwhelming for thehigh risk of injury for those bare-foot runners with lack of protectivesensation.21-22 One study claimed in-creased impact and another notedan increase of shock transmissionto the lower back with barefootrunning. It appeared that theseparadoxical findings were the resultof the subjects being required torun with a heel strike while un-shod.23,24

Minimalist ShoesIn an effort to be included in

the barefoot running mania, someshoe companies have developedshoes that mimic barefoot running(minimalist shoes). The runner cangarner the benefits from utilizationof a barefoot running form buthave some basic protection fromsurface hazards. The restrictionsand confinements of running shoesare eliminated. The Nike Free andVibram 5 Fingers are currently thebest known, but other companieshave released their own models orhave them in development.

The Coaches’ PerspectiveAlthough not scientific evidence,

anecdotal discussion with coachessheds light on some perceived short-comings as well as pluses to barefootrunning. Firstly, a number of coach-es believe that utilization of barefootrunning as part of the overall train-ing program (as the author did inhigh school) is beneficial forstrengthening intrinsic musculature

Barefoot Running...

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60 www.podiatrym.comPODIATRY MANAGEMENT • NOVEMBER/DECEMBER 2010

Though it is

undeniable that

surface hazards exist,

there is really no

evidence that they

pose a risk to those

running barefoot.

have a distinct gait pattern that isquite different from that of a shodrunner.

* but there is no evidence toshow that these changes result inreduced injuries or improved per-formance.

2) Those running barefoot ap-pear to experience reduced impact(collision) forces at foot strike.

* but attenuation of the forcesby calf musculature may result inmyotendinous injury such as

and improving form but observed(as did a number of clinicians) theirrunners getting overuse injuries as aresult of overzealous incorporationof barefoot running. Ironically, run-ners who procured minimalist shoessuch as Vibram 5 Fingers seemed tohave even more injuries due to afalse sense of “protection” when thepurely barefoot condition wouldprovide better feedback to take iteasier. (Verbal communication,Coach Bill Strachan, MS July 2009)

Advising Your RunnersOne of your running patients

presents to your office with a multi-tude of questions about barefootrunning and/or minimalist shoes.He indicates that he is consideringbarefoot running but would likeyour opinion. Evidence as well asexperiences of fellow clinicians canbe used to guide you. Some basicgeneralizations follow:

1) Those running barefoot do

Achilles tendinopathy.* but there is no evidence to

show that reduced impact results inreduced injuries or improved per-formance.

3) Those who are barefoot dohave an improved proprioceptivefeel for the surface and better jointposition sense.

* but there is no evidence toshow that this results in reduced in-juries such as ankle sprains or im-proved performance.

4) Some evidence exists thatsupports increased strength andsize of the plantar intrinsic muscu-lature in those who run barefoot.

* but there is no evidence toshow that this results in reduced in-juries or improved performance.

5) Some evidence exists thatbarefoot running has more efficientenergy utilization.

* but there is no evidence toshow that this results in reduced in-

Barefoot Running...

Continued on page 63

62 www.podiatrym.comPODIATRY MANAGEMENT • NOVEMBER/DECEMBER 2010

Some evidence exists

that supports

increased strength and

size of the plantar

intrinsic musculature

in those who run

barefoot.

3 Robbins SE, Hanna AM: Running-related injury prevention through bare-foot adaptations. Med Sci Sports Exerc19: 148, 1987.

4 Robbins SE, Gouw GJ: Athleticfootwear: unsafe due to perceptual illu-sions. Med Sci Sports Exerc 23: 217,1991.

5 Ken Bob Sax ton : Runn ingBarefoot Web site. http://runningbarefoot.org/. Accessed March 27,2009.

6 Barefoot Ted’s Adventures WebSite. http://www.barefootted.com/

index.php?q=/. Accessed July 20, 2009.7 Divert C, Mornieux G, Baur H, et

al.: Mechanical comparison of barefootand shod running. Int J Sports Med 26:593, 2005.

8 Squadrone R, Gal lozz i C:Biomechanical and physiologicalcomparison of barefoot and two shodconditions in experienced barefootrunners. J Sports Med Phys Fitness49: 6, 2009.

9 Lieberman D, Venkadesan M,Werbel W, et al.: Foot strike patterns

Barefoot Running...

juries or improved performance.

6) The evidence is clear thatrunning barefoot would be riskyfor those with loss of protectivesensation.

7) Although there is no evi-dence one way or the other, itwould seem that those patientssuccessfully treated with motioncontrol shoes and/or orthotics fora biomechanically related condi-tion would not be well served tobegin a barefoot running pro-gram. Having said that , i t i sworth mentioning that barefootrunning af ic ionados wouldcounter that the changes in form,strengthening of musculature etc.could eliminate the biomechani-cal weakness or prevent it in thefirst place.

8) It would seem that the mostimportant advice you can giveyour patient would be 1) choose asafe surface and 2) build up activi-ty as slowly as one beginning ajogging program who has neverjogged before, so as to allow theosseous and soft tissue structurestime to adapt.

Key PointA common theme in the above

conclusions is that there is no evi-dence to support that barefootrunning reduces injuries or im-proves performance, but it is veryimportant to point out that the ev-idence does not support that bare-foot running increases injury or re-duces performance. Some of theclaims may very well pan out to betrue, but much more research isneeded. �

References1 American Podiatric Medical Asso-

ciation/American Academy of PodiatricSports Medicine Position Statement onBarefoot Running. APMA Website.http://www.apma.org/MainMenu/News/MediaRoom/Posit ionStatements/APMA-Position-Statement-on-Barefoot-Run Accessed November 9, 2009.

2 McDougall C: Born to Run: A Hid-den Tribe, Superathletes, and the Great-est Race the World Has Never Seen. 1stedition, Alfred A. Knopf/RandomHouse, New York, 2009.

Continued on page 64

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thotics on VO2 and selected frontalplane knee kinematics. Med Sci SportsExerc 17: 158, 1985.

16 Catlin MJ, Dressendorfer RH: Ef-fect of shoe weight on the energy costof running. Med Sci Sports Exerc 11: 80,1979.

17 Flaherty R: Running economyand kinematic differences among run-ners with foot shod, with the foot bare,and with the barefoot equaled forweight. [abstract].1994 [cited June2009]. Available in SPORTDiscus withfull text.

18 van Haalen FM, Bruggink SC,Gussekloo J, et al.,: Warts in primaryschoolchildren: prevalence and relationwith environmental factors. Br J Derma-tol 161: 148, 2009.

19 Laughlin TJ, Armstrong DG, Ca-porusso J, et al.: Soft tissue and bone in-fections from puncture wounds in chil-dren. West J Med 166: 126, 1997.

20 Pallar, A: Getting a Jump on Ath-letes Foot. Dermatology Insights 3: 30,2002.

21 Lavery LA, Walker SC, HarklessLB, et al.: Infected puncture wounds indiabetic and nondiabetic adults [erra-tum in: Diabetes Care 19: 549, 1996].Diabetes Care 18: 1588, 1995.

22 Jayasinghe SA, Atukorala I,

and collision forces in habitually bare-foot versus shod runners. Nature 463:531, 2010.

10 Robbins S, Waked E, McClaranJ: Proprioception and stability: footposition awareness as a function ofage and footwear. Age Ageing 24: 67,1995.

11 Robbins S, Gouw GJ, McClaran J:Shoe sole thickness and hardness influ-ence balance in older men. J Am GeriatrSoc 40: 1089, 1992.

12 Kurz MJ, Stergiou N: Doesfootwear affect ankle coordinationstrategies? JAPMA 94: 53, 2004

13 Rao UB, Joseph B: The influenceof footwear on the prevalence of flatfoot. A survey of 2300 children. J BoneJoint Surg Br 74-B: 525, 1992.

14 Brugemann G,, Potthast W,Braunstein B, et al.: Effect of increasedmechanical stimuli on foot musclesfunctional capacity [online abstract].In: ISB XXth Congress—ASB 29th An-nual Meeting. Cleveland, OH: Ameri-can Society of Biomechanics;2005:553.

15 Burkett LN, Kohrt WM, Buch-binder R: Effects of shoes and foot or-

Gunethilleke B, et al.: Is walking bare-foot a risk factor for diabetic foot dis-ease in developing countries? Rural Re-mote Health 7: 692, 2007.

23 Komi PV, Gollhofer A, Schmidt-bleicher D, et al.: Interaction betweenman and shoe in running: considera-tions for a more comprehensive mea-surement approach. Int J Sports Med 8:196, 1987.

24 Ogon M, Aleksiev AR, Spratt KF,et al.: Footwear affects the behavior oflow back muscles when jogging. Int JSports Med 22: 414, 2001.

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64 www.podiatrym.comPODIATRY MANAGEMENT • NOVEMBER/DECEMBER 2010

Dr. Jenkins is aProfessor at theArizona Schoolof PodiatricMedicine-Mid-western Univer-sity as well as aFellow andBoard Memberof the AmericanAcademy of Po-diatric Sports Medicine. He is also theClinical Director for the SpecialOlympics Arizona Fit Feet Program andPodiatric Consultant for the Los AngelesDodgers.