Barefoot running survey: Evidence from the field???

I am in a cranky mood this morning. I put off reviewing this one as I new what I was going to write was not going to be complementary and I had other more interesting papers to review and comment on. I finally got to it as couple of fan boys emailed me asking me why I was ignoring this “evidence” (what evidence?) and there has been some recent social media comments on the study from other fan boys with comments like “the numbers don’t lie”. Isn’t it intriguing that a publication does not say that at all, yet people interpret it that way. I have always said that the issue I have with the fan boys (some call it an obsession) is the misuse, misinterpretation, misunderstanding, misquoting and straight out making up stuff about research. Here is the study in question:

Barefoot running survey: Evidence from the field
David Hryvniak, Jay Dicharry, Robert Wilder
Journal of Sport and Health Science; Volume 1, Issue 2, June 2014, Pages 131–136
Background
Running is becoming an increasingly popular activity among Americans with over 50 million participants. Running shoe research and technology has continued to advance with no decrease in overall running injury rates. A growing group of runners are making the choice to try the minimal or barefoot running styles of the pre-modern running shoe era. There is some evidence of decreased forces and torques on the lower extremities with barefoot running, but no clear data regarding how this corresponds with injuries. The purpose of this survey study was to examine factors related to performance and injury in runners who have tried barefoot running.
Methods
The University of Virginia Center for Endurance Sport created a 10-question survey regarding barefoot running that was posted on a variety of running blogs and Facebook pages. Percentages were calculated for each question across all surveys. Five hundred and nine participants responded with over 93% of them incorporating some type of barefoot running into their weekly mileage.
Results
A majority of the participants (53%) viewed barefoot running as a training tool to improve specific aspects of their running. However, close to half (46%) viewed barefoot training as a viable alternative to shoes for logging their miles. A large portion of runners initially tried barefoot running due to the promise of improved efficiency (60%), an attempt to get past injury (53%) and/or the recent media hype around the practice (52%). A large majority (68%) of runners participating in the study experienced no new injuries after starting barefoot running. In fact, most respondents (69%) actually had their previous injuries go away after starting barefoot running. Runners responded that their previous knee (46%), foot (19%), ankle (17%), hip (14%), and low back (14%) injuries all proceeded to improve after starting barefoot running.
Conclusion
Prior studies have found that barefoot running often changes biomechanics compared to shod running with a hypothesized relationship of decreased injuries. This paper reports the result of a survey of 509 runners. The results suggest that a large percentage of this sample of runners experienced benefits or no serious harm from transitioning to barefoot or minimal shoe running.

This was a self-selected online survey of runners. What is wrong with this sort of methodology? … well, its a self-selected online survey. These types of self-selected online surveys are so biased that they sit pretty close to the bottom of the pile when it comes to a hierarchy of evidence, so it does not really provide “Evidence from the field”. Some of the biases in these types of study include selection bias, recall bias, attribution bias and self delusion or psychological needs biases (the authors did acknowledge some of these biases in their discussion). At best it is a descriptive survey of what those who have successfully transitioned to barefoot running did it for and what they do. That is all. It is not evidence that barefoot running is better, that all the systematic reviews of all the evidence are showing that its not. There was no data on those who failed in the transition to barefoot running to compare it to and there was no control group.

Even the discussion of the results of the study by the authors falls short of what I would consider academically rigorous. It paints a very different picture of barefoot running and its alleged benefits than what ALL the formal systematic reviews of the evidence paint. How did the authors of the above study reach different conclusions than those systematic reviews? They did it by cherry picking the evidence, They failed to quote any references that contradict the views that they were trying to espouse. Good science does not progress this way. Bad science and pseudoscience “progress” (?regress) that way. They even totally misquoted studies. The worse was probably the Ryan et al (2009) study:

Ryan et al found that runners with chronic plantar fasciitis using minimal shoes had an overall reduction of plantar foot pain earlier than traditional cushioned shoe runners.

They did not find that. I discussed this study here. The authors missed that this study failed to use the intention to treat analysis and that there were dropouts in the minimalist group as their pain got so bad, meaning that that study probably showed the exact opposite. Blindly quoting a study without critical appraisal is a failure of academic rigor (let alone the peer review process that let this point and others slip through).

This would have been an OK study if it was presented for what it was and was not wrapped in the cherry picked discussion and the misuse, misinterpretation, misquoting of other research …. not to mention the misuse, misinterpretation,  misunderstanding, misquoting of the above study by the fan boys in social media (and in emails to me!).

As always, I go where the evidence takes me until convinced otherwise and ….. well …. isn’t it obvious?

Hryvniak, D., Dicharry, J., & Wilder, R. (2014). Barefoot running survey: Evidence from the field Journal of Sport and Health Science, 3 (2), 131-136 DOI: 10.1016/j.jshs.2014.03.008

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About Craig Payne

University lecturer, runner, cynic, researcher, skeptic, forum admin, woo basher, clinician, rabble-rouser, blogger, dad. Follow me on Twitter, Facebook and Google+

11 Responses to Barefoot running survey: Evidence from the field???

  1. Kevin A. Kirby, DPM July 12, 2014 at 10:59 pm #

    I call this type of study an example of “grasping at straws”. The barefooters so desperately want to have their beliefs confirmed that they will convince themselves that this type of study is rigorous proof that barefoot running is better.

    The researchers may as well have posted a 10-question survey on a variety of blogs and Facebook pages regarding their views on religion. That would have been good evidence on the best religion, now wouldn’t it?!

    Benno Nigg claims that the next barefoot running boom will be in 25 years…..can’t wait for that to happen…

    Cheers,

    Kevin

  2. Ian Griffiths July 13, 2014 at 9:45 am #

    The week just gone I saw 3 individuals with issues associated with them switching to “barefoot” shoes (an Achilles tendinopathy and two cases of MTPJ synovitis/plantar plate disruption). This has been fairly standard over the last 3-4 years or so; approx 2-3 of the 20 new patients I see a week have had similar stories. Looking at these numbers that works out to be approaching 500 cases.

    However, quite clearly this is also a cohort which is not representative of the population, as people who transition successfully and do well (maybe even significantly benefit from the changes made) clearly will seldom come to my door. Publishing this data would also be guilty of the bias pitfalls explained in the post. The discourse between the above n=500 report and my own n=500 observations also highlights for me why this sort of research adds little to the evidence base. As you rightly point out Craig – all this will be used for is as cherry picked ammunition for those with a polarised position/financial interest.

    Anyone who has been around runners/athletes for the last 4 years knows that anecdotally these sorts of changes only work for some of the people some of the time. We also have good evidence (Tam’s paper in the BJSM to name but one) telling us we cannot currently conclude that one size fits all, and we certainly don’t have the data to suggest what is “best” (and this very much mirrors what most of us see clinically).

    It still amazes me how much momentum this “debate” has…

  3. blaise Dubois July 13, 2014 at 2:58 pm #

    Hi the “protective boys” (to opposite the appellation of the “fan boys”… with the sens to protect: feet, business, ideas, … :)

    This study has nothing special for me. It’s not the best device to know the truth about risk of injuries for barefoot runners. I agree that the discussion is weak and far from a good review on this topic, but it was not the objective of this study.
    What’s interesting is the result of the study: running barefoot successfully is not anecdotal and it was possible for most of the runners that answered to the survey… they did it and did well.

    So, I agree, it’s not evidence that barefoot running is better… but there is NO evidence that shoes are better than barefoot either.

    ALL the formal systematic reviews don’t show that shoes are better than barefoot
    OR than big bulky shoes (traditional / maximalist / TRC rating 70% / 5to20% of the market)

    If you are fair and knowledgeable with the evidence, you know that there is:
    Low Quality Evidence with High Risk of Bias that experienced minimalist shoe wearers are less injured than experienced traditional/maximalist shoe wearers
    AND
    Low Quality Evidence with High Risk of Bias that new minimalist shoe wearers are more injured than experienced traditional/maximalist shoe wearers
    AND
    No Evidence that new traditional/maximalist shoe wearers are more injured than experienced minimalist shoe wearers

    So with this lack of evidence, who should bear the burden of proof? Those who initially came up with maximalist and more modern running shoes or those who are currently promoting getting back to basics?

    I think that the burden of proof should be on:
    1. Those who advocate MINImalism when it comes to changing long-established habits (I’m referring to bulky modern shoes).
    2. Those who advocate MAXImalism when it comes to recommending something other than simplicity for beginners and children.

    Q #1: Ian, Graig and Kevin : What do you recommend for most of beginner and children? I debated with all of you and none of you “protection boys” has answered clearly to the question

    Q#2: I’m intrigued if you consider me as a part of the “fan boys”?

    Best
    Blaise

  4. Kevin A. Kirby, DPM July 13, 2014 at 10:35 pm #

    Blaise:

    If you think that I recommend what you like to call “big, bulky shoes” for the children I treat, then you are sorely mistaken. As I have told you numerous times before in our previous interactions, my prescription for shoes is based on age, foot type, current injury site, body weight, type of sports, experience in sport and foot and lower extremity biomechanics, in addition to other less important factors.

    Now that I am in my 30th year of treating children’s foot conditions, have been running for over four decades and lecture frequently on children’s flatfoot deformity both nationally and internationally, I can clearly state that just looking at shoe sole thickness and heel height differential of shoes, without considering other factors in a child’s foot and lower extremity, you are missing out on some of the more important aspects of treating children’s foot and lower extremity injuries.

    As for beginning runners, again I base my shoe recommendations on age, foot type, current injury, body weight, other types of sport, experience in sport and foot and lower extremity biomechanics, in addition to other less important factors. Here in Northern California, it is probably sad for you to know that minimalist shoes are on the way out and Hoka One One and other thicker soled maximalist shoes are becoming more and more popular. A months ago I asked Benno Nigg, one of your fellow Canadiens, if he had heard of you, he said “Who????” I guess you aren’t very well known even in your own country by the other running biomechanics experts. I think you should work on becoming more well-known so that, maybe, more people will start listening to your barefoot-minimalist shoe-natural running message you promote in your pay-to-attend seminars.

    I am very sorry that your beloved minimalist shoes that you have been promoting for the past few years as producing fewer injuries are being put into the back of the closet and runners are selecting to run in more thick-soled, cushioned shoes? Could it be that what you have been promoting and teaching in your pay-to-attend running clinics over the past few years is simply your opinion with no basis in fact?

    Please also tell me, Blaise, what do “simplicity” shoes look like for beginners and children???

    Cheers,

    Kevin

    • blaise Dubois July 14, 2014 at 12:49 pm #

      Like always you prefer attack the messager than really think… and answer clearly to the question. I was not peaking about the 1 special case on 1000 children (treating a specific foot deformity or pathology) but your general recommandation for beginner and children…

      If your prescription for shoes is based on age, foot type, body weight and foot and lower extremity biomechanics : can you explain? … I feel you do the same thing that what’s explain and recommend shoe companies? Huuummmm

      To simplify, juste tell me what you do with the 120pounds vs the 200pounds male ;)

    • Paul July 15, 2014 at 2:58 pm #

      This seems to be getting quite angry. I just felt I should say As a physio and a runner; all courses I go on with leading experts are “pay-to-attend”.

      I found Blaise Dubois’ course excellent value for money. I didn’t feel he was pushing the barefoot message but just asking questions of the science, of which he has a very good awareness and a very critical approach.

      Attacking him because Benno Nigg doesn’t know of him doesn’t strengthen your argument in my opinion.

      • Kevin A. Kirby, DPM July 15, 2014 at 7:42 pm #

        Paul:

        Blaise and I have quite a history discussing things on Podiatry Arena. Maybe that explains my tone with him.

        By the way, Chris McDougall also called me the “Angry Podiatrist”.

        http://www.chrismcdougall.com/blog/2010/02/but-what-about-glass/

        Funny, the only people who find me angry are the ones touting the barefoot and minimalist shoe and anti-rearfoot striking running message….wonder why that is…??

        Cheers,

        Kevin

  5. droichead July 14, 2014 at 6:58 pm #

    Kevin,

    In the line of Blaises questions. I would be more specific:

    1) For a 10 year old, with no foot conditions, sane and standard biomechanics, which is interesting in running which running shoe would you recoomend? An old school running flat? and if this is not the case why?

    2) While it is absolultely true that *SOME* barefoot/minimalist running advocates have made absurdly strong statements with absolutely no scientific proof of it, and this page rightfully attack that attitude. Now that you have mentioned Benno Nigg, I would say that he has been one of the strongest critics of cushioning and motion control/overpronation runners in having any benefit on reducing injury risk for many years. Still, nearly every single running company keeps selling runners based on this classification. I agree that, unlike others, they are wise enough to avoid stupid claims ala Vibram, but, given the lack of evidence of their paradigma, why blogs like this or people like you do not dedicate the same time attacking and effort both “zealots” (sure, they have different styles, but their lack of scientific evidence is the same).

    PS: I do not have a particular position on this debate, and I usually enjoy reading Craigs blog, although I find him a bit biased sometimes, but that is just a personal oppinion (and I am the first stating that some barefoot radical advocates are completely biased and unreasonable in their statements).

    • Kevin A. Kirby, DPM July 14, 2014 at 7:19 pm #

      For a 10 year old, with no foot pathology, I tell the parents to buy them a thinner soled running shoe to match their reduced body weight. Many times, a racing/minimalist shoe is sufficient for this age group. However, most children of this age aren’t doing distance running, they are playing soccer, basketball, football, baseball so I don’t really see 10 year old distance runners very often.

      I have no problems with people running in “minimalist shoes”, running barefoot or running in traditional or “maximalist shoes”. However, I do have problems with self-proclaimed “experts” who condemn all thick-soled running shoes with a certain heel-height differential (a.k.a. heel drop) or who condemn rearfoot striking running as being unhealthy or injury-causing. Where is the research evidence for their bizarre proclamations?? There is none.

      That is the point. If people are reasonable and objective, then I leave them alone. There is not any one best running shoe for every runner. Every runner has individualized needs in regards to running shoe design. Some do best barefoot, some do best in “minimalist shoes”, some do best in traditional running shoes and some do best in “maximalist shoes”. That is all fine with me. As long as they can train without pain and injury in the shoe they choose to run in, then I have no problems with any running shoe design (or running barefoot for that matter).

      However, when these self-proclaimed “experts” start pushing only one type of running shoe, or start pushing barefoot running, as being the best way for everyone to run, then that is when I speak up to prevent others from being injured from their statements. My job as a sports podiatrist is to keep people from getting injured and help people heal from their injuries. Nothing more, nothing less.

      Cheers,

      Kevin

  6. droichead July 14, 2014 at 7:39 pm #

    Kevin,

    Thanks for your answer. We agree.

    In relation to the first question, I was talking about long distance runinng obviously which as you say happens to be a minority. Other sports with other requirements need different type of shoes (although when I think about the basketball shoes I used in the 70-80s they look minimal to me when compared to “modern” ones).

    In relation to my second question, I am on the same line of thinking, every runner is different and have different needs. But in my oppinion, many people (and here I mean average amateur runners) could run with much less “shoe” than they really do. This does not mean “minimalist” but just a bit less. I am not stating that there is evidence that this is neccesary “better” which is a completely different issue.

    The bottom line to me is, that while the “minimalist” current could have brought an interesting argument to the dialog, the noise create by some unfounded, non scientific minority of zealots , completely distorts the debate. A pity.

    • Kevin A. Kirby, DPM July 15, 2014 at 2:58 pm #

      Thin-soled shoes are the norm for side-to-side sports such as basketball, football, soccer, tennis, racketball, squash, baseball, etc. Thin-soled shoes will decrease the moment arm for ground reaction force to cause excessive subtalar joint pronation and supination moments during side-to-side activities and, therefore, thin soles are often used for shoes made specifically for these sports. However, for straight-ahead activities such as running and walking, shoes with thicker soles may be used since the magnitude of medial-lateral shear forces from ground reaction force is much less in walking and running than in the side-to-side sports. In other words, you can walk and run fairly comfortably and safely in shoe with a thicker sole but would not be comfortable or safe to wear these shoes in high intensity side-to-side sports.

      While it is true that many runners could wear a lighter weight shoe than they currently do, they may also be increasing their risk of injury in doing so. In all treatments in medicine, we must weigh the benefits versus the risks of that treatment. The same goes for running shoe recommendations, I tend to err on the safe side for my runner patients in my recommendations since I am a health professional and my job is to keep my patients safe.

      Thanks for the discussion. Good stuff.

      Cheers,

      Kevin

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