Examining injury risk and pain perception in runners using minimalist footwear

All the rhetoric and propaganda over recent years is that minimalist or running barefoot running will reduce the risk of injury. The preponderance of the recent research on injury rates has not supported that. Now we have this new study to add to the mix:

Examining injury risk and pain perception in runners using minimalist footwear
Michael Ryan, Maha Elashi, Richard Newsham-West, Jack Taunton
Br J Sports Med; Published Online First 19 December 2013
Background: This study examines the effect of progressive increases in footwear minimalism on injury incidence and pain perception in recreational runners.

Methods: One hundred and three runners with neutral or mild pronation were randomly assigned a neutral (Nike Pegasus 28), partial minimalist (Nike Free 3.0 V2) or full minimalist shoe (Vibram 5-Finger Bikila). Runners underwent baseline testing to record training and injury history, as well as selected anthropometric measurements, before starting a 12-week training programme in preparation for a 10 km event. Outcome measures included number of injury events, Foot and Ankle Disability (FADI) scores and visual analogue scale pain rating scales for regional and overall pain with running.

Results: 99 runners were included in final analysis with 23 injuries reported; the neutral shoe reporting the fewest injuries (4) and the partial minimalist shoe (12) the most. The partial minimalist shoe reported a significantly higher rate of injury incidence throughout the 12-week period. Runners in the full minimalist group reported greater shin and calf pain.

Conclusions: Running in minimalist footwear appears to increase the likelihood of experiencing an injury, with full minimalist designs specifically increasing pain at the shin and calf. Clinicians should exercise caution when recommending minimalist footwear to runners otherwise new to this footwear category who are preparing for a 10 km event.

The conclusions made by the authors were pretty clear:

Injury event analysis showed there was a higher likelihood of experiencing an injury with minimalist footwear compared with a conventional neutral shoe model, with the partial minimalist condition having a particularly higher risk.

Where the study may fall down (or at least where the fan boys are going to call the study fatally flawed and unethical) is on the adequacy of the transition to the minimalist shoe groups. The participants were given a “1-week break in period to their assigned footwear“, then began the 12 week training program. The program did follow a gradual increase in distances that were run, so should have facilitated the transition in the two minimalist groups. Is the 12 weeks adequate? This issue was discussed at depth in the discourse that surrounded the bone stress injury and Vibram running shoes study. That study did follow the advice of 12 weeks advised on the Vibram website, but the fan boys in their social media comments considered that unethical and woefully inadequate.

I guess it all comes down to which end of the spectrum that you sit, your world view and what color blinkers you use to interpret this study. At one end, this study shows that if you wear minimalist shoes you are more likely to get an injury. At the other end of the spectrum this just confirms what we know about the increased risk for injury in the transition to minimalist shoes and the need to do it cautiously. This study did not investigate what happened to injury rates following the 12 week training program.

As always, I go where the evidence takes me until convinced otherwise, and this study confirms the injury risks associated with minimalist footwear.

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17 Responses to Examining injury risk and pain perception in runners using minimalist footwear

  1. Kevin A. Kirby, DPM December 20, 2013 at 8:12 pm #

    I smell the end of the minimalist running shoe fad and Chris McDougall’s 15 minutes of fame with this study….good riddance!!

    • blaise Dubois December 24, 2013 at 2:10 am #

      don’t forget to read the article 🙂

    • Mark Richard December 25, 2013 at 11:40 am #

      Time will tell

  2. Geoffrey Gray December 20, 2013 at 9:49 pm #

    Very interesting. It is still surprising that the Free/partial minimal had almost double the number of injuries as the Bikila/Full Minimal. Perhaps unstable foam is worse than no foam at all as far as injury.

    On the flip side: 23% injury rate does seem reasonable based on past research. But wouldnt it be great if we could get injury rates in runners much lower than that?

  3. Peter Larson December 23, 2013 at 8:45 pm #

    If I’m not mistaken, based on the relative risk data reported in the supplemental info there was no significant difference in injury risk between the Pegasus and the Vibrams, just between the Pegasus and Free. So another study saying go with what works best for you?

    Absolute Risk Reduction: Free vs. Pegasus -25.0 [-43.8 – -3.7] %, Vibram vs. Pegasus -7.5 [-25.1 – 11.0] %
    Relative Risk: Free vs. Pegasus 310 [111.9 – 857.2] %, Vibram vs. Pegasus 160 [51.6 – 495.8] %

  4. blaise Dubois December 23, 2013 at 11:08 pm #

    Hi guys,
    My opinion: have more rigour, read the article up to the end and stop to speak about ‘fan boys’.

    The conclusion should be (for more accuracy) like that: Recreational runners used to wearing traditional shoes and who were assigned a new partial minimalist shoe (Nike Free 3.0, 10 minutes more per week for 12 weeks) showed a significantly higher risk of injury (more precisely at the calf and shin) … AND

    Recreational runners used to wearing traditional shoes and who were assigned a full minimalist shoe (5-Fingers, 10 minutes more per week during 12 weeks) did NOT show a significantly higher risk of injury, but rather a higher likelihood of developing pain at the calf and shin

    More info on : http://www.therunningclinic.ca/blog/2013/12/premiere-etude-randomisee-controlee-minimalistes-vs-maximalistes-first-published-randomized-controlled-trial-minimalist-vs-maximalist-running-shoes/

  5. Christian December 26, 2013 at 12:49 pm #

    Blaise I agree with what you are saying however as a consumer if one was to tell you you were to experience an increased injury risk if you switch to a nike 3.0 or more likelihood of pain to your shins and calf if to switch to a pair of vibrams what would you choose?

    I actually don’t think the project says much at all and think people put way too much emphasis on footwear without addressing bigger issues ( mind you there’s a big difference between a bad pair of shoes and a suitable pair).

    Perhaps we need to move away from footwear and put our focus elsewhere

    • blaise Dubois December 27, 2013 at 3:49 am #

      One of my fist recommendation to runners is to not change habits

      Keep your big bulky shoes IF
      – you are use to wear it
      – you are not injured
      – you don’t want to improve your performances

      I have the bias to be a clinician that see injured runners and runners that come see me to improve their performances…

      About the conclusions I wrote above it’s the result of the study. My hypothesis will be write more like that :
      Recreational runners used to wearing traditional shoes and who were assigned a full minimalist shoe (5-Fingers, 10 minutes more per week during 12 weeks) will have higher risk of injury than moving to the Nike Free or keeping the type of shoes, especially developing pain, soreness or injuries at the calf and shin and foot…

  6. Christian December 27, 2013 at 5:44 am #

    Sorry I apologise if I’ve misinterpreted you but you seem to have originally re-phrased the studies conclusion to insinuate that Nike free’s increase your chance of injury and that vibram
    Five fingers increase the likiehood of experiencing shin and calf pain.

    Yet your comment above suggests that those who transition from a structured running shoe to a pair of vibrams will experience an increased injury risk and that you reccomend a transition period with the Nike free?

    You mention that this is your hypothesis so therefore I am assuming the later comment doesn’t refer to your interpretation of the study?

    Would you consider those who don’t progress through the transition phase and remain in a pair of nike free 3.0 are putting themselves at risk of injury based on the findings of this article?

    And if that is the case does your own interpretation of the research not conflict with your hypothesis? I.e. In order to run faster and at lower risk to injury you must first put yourself at a heightened risk to injury by wearing a “transition” shoe?

    Thanks for your reply. I am at no way having a go at you as I find alot of what you say to be pretty thought provoking. Just trying to better understand your position on this

    • blaise Dubois December 27, 2013 at 2:48 pm #

      Hi Christian,

      Yes I re-phrased the conclusion of the study for more accuracy (see on our blog the reaction/discussion with Michael Ryan (main author).

      Yes, my hypothesis/opinion/conviction is: those who transition from a structured running shoe to a pair of vibrams will experience an increased injury risk IF the transition period is too short.

      Yes this study don’t show that! it’s show that recreational runners used to wearing traditional shoes and who were assigned a full minimalist shoe (5-Fingers, 10 minutes more per week during 12 weeks) did NOT show a significantly higher risk of injury.

      Yes, I think (opinion/hypothesis) AND the article show that those who move from a traditional shoe to a pair of nike free 3.0 are putting themselves at risk of injury (10 minutes more per week during 12 weeks)

      Yes, the RESULT (not my interpretation) of the research is conflicting with MY hypothesis. (about the 5F …. not the Free)

      To conclude, I think that: changing has some risk on short term; you can listen your body and be smart with the transition and not be injured; moving to less shoes is one of the more efficient way to improve your performance (first by the weight you take off); minimalist wearer have a little less risk to be injured than traditional wearer. I recommend to beginners to start with minimalist shoe and to children to wear very minimal shoe.

  7. Christian December 31, 2013 at 12:29 am #

    Thanks for your reply Blaise.

    I admit I enjoy running in my vivo’s and 3.0 but also acknowledge for some it’s just not an option. But that’s my opinion which doesn’t automatically make it right.

    Again, I appreciate you taking the time to respond.

    All the best for 2014

    Christian MAC

  8. Brad January 11, 2014 at 12:39 pm #

    Apart from the patently obvious: ridiculous transition time-scale & athletes being most likely to take even longer to rid themselves of ingrained, sub-optimal movement patterns …

    1. If you go into a gym and start stressing muscle, bone and connective tissue that you’ve never worked-out before … we expect to feel some pain from inflammation?
    2. We accept that given the requisite nutrition/sleep/recovery time etc. the tissue adapts to come back “stronger” and perform better?
    3. How don’t people understand that this applies to the feet and legs?

    When it’s known that even a sock has a dramatic effect on proprioceptive feedback, why are we surprised when an ultra-thin sole wakes up our brain more than a pseudo-minimalist (Nike Free) and forces us to look for new movement options … thereby stressing the tissues that “are normally worked-out”?

    In time the relevant studies should tally with common sense.

    • Craig Payne January 11, 2014 at 7:01 pm #

      What is exactly is ridiculous about the transition time? Its what Vibram recommended on their website.The researchers were only following the manufacturers instructions.

      • Ajur February 1, 2014 at 4:40 pm #

        In my experience, I started running with Vibrams once in 4 days, about 4 km each time. I only managed to lengthen my runs once I stopped running on trails full of pine cones. Once I chose more smooth trails, I could run about 7km shortly and the running times had already improved at least to what I had been able to run in traditional shoes. So at the end of the 12 week period I was at 7 km, and the interval was still about twice per week because of recovery. My total running distance had reached about 130 km by then – not nearly enough to try 10 km in a race, barely enough to try it alone maybe once per fortnight. My point is that one needs to get at least 500 – 1000 km experience with Vibrams (or barefoot) before one is ready for a 10km race (and usually my average monthly distance does not go over 100 km, so even by that metric the transition takes at least 5-10 months). I am now at around 1700 km after 4 years and I can jog 10km at once even after a 5-week hiatus (so I am not much of a runner, actually). I have tried 12km runs, but those are still a bit too much for baseline.

        One cannot transition with 12 weeks, unless one also constantly performs additional special strengthening exercises every day, several times per day. Walking 5-10km per day also helps to relax the muscles. So, I guess (I haven’t read the Vibram recommendations, nor the article) the research neglected special strengthening exercises and relaxing everyday walks.

        I was lazy, so I chose the slow approach. And I am happy with the transition. And I would buy ordinary sneakers only for bicycling now.

  9. Brad January 12, 2014 at 5:54 pm #

    Hey Craig, this is a great blog.

    I’m not going to knock Vibram – you lead a “new” category, you make mistakes, you correct problems that arise. As far as I am aware those were guidelines from an earlier webpage of theirs (but I stand open to correction). The fact that people today go to court over injuries, blaming a piece of text is another issue.

    The problem is more that as a consumerist society, we are accustomed to buying-in a quick fix and following a “trend”.
    Every body has had unique set of environmental variables thrown at its genetic & epigenetic make-up. To assign a prescriptive transition period is foolish.

    Ask any structural integration/bodywork practitioner – although athletes have great “body awareness”, high volume repetition causes very specific tissue changes and motor patterning. Fortunately throughout our lives we retain plasticity … otherwise as a species we’d have been toast some time back.

    1. You educate people to look through decades of marketing, understand the basics of how their bodies function.
    2. You encourage them to learn to listen to the feedback from their bodies, thus regulating exposure to a new stimulus.

    The latest OLED iWatch is a doorstop compared to the self-assembled, self-maintaining hardware/software in the human body.
    Those bona fide “minimalist” manufacturers who have the budget capacity, have since been been investing in musculoskeletal & technique education.

  10. Phil Earnhardt August 9, 2014 at 2:19 pm #

    The message I get from the study is that most adults and most recreational athletes have underdeveloped intrinsic muscles in the feet, and that developing those intrinsics takes far longer than “breaking in” a new pair of shoes for one week.

    I appreciate the resource strain on longer research studies, but I would love to see a study where runners had a six-month period to transition to the minimalist shoes — possibly where they were doing supplementary work to develop the small support structures in their feet.

    • Craig Payne August 9, 2014 at 2:25 pm #

      The study does not come remotely close to showing that at all!!!! .. and it made no findings at all on the intrinsic muscles!!! Other studies do not support what you are asserting.

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