Foot Strike Pattern and Injury Rates

Like the running economy and footwear type issue, I have been meaning to write for a while an article that summarizes the studies on the differences in injury rates between heel strikers and non-heel strikers; but before I got to doing it another two studies appear, so its worth writing about those. To date we have 4 studies (now 6) that have looked at this:

  • Daoud et al (2012) was a retrospective review of 52 almost elite level track runners (that are not close to being representative of typical runners) which found the injury rate in the heel strike group was almost double the forefoot striking group. This study got an extraordinary amount of press coverage (and Vivobarefoot cherry picked it to produce a  poster).
  • Kleindienst (2003)  was a retrospective review  of 471 typical runners that found no difference between rearfoot and forefoot strikers concerning the frequency of injury.
  • Walther (2005) was a retrospective review of 1203 runners that also found no difference in incidence of injury between rearfoot and forefoot strikers in the rate of injury.
  • Goss & Gross (2012) was a self-selected, self reported web based survey that reported data from 1605 runners that no one is giving much weight too (except this loon) due to the self-selected nature of the study design. They did report that traditionally shod runners were 3.4 times more likely to get an injury that a minimalist runner.

The first new study is by Grier et al and is being presented at next weeks American College of Sports Medicine meeting, was also a retrospective study design. They looked at 1332 soldiers of which 17% were wearing minimalist running shoes. They reported that in the abstract that “When controlling for personal characteristics, physical fitness, and a history of prior injury, there was no difference in injury risk in the previous 12 months between soldiers wearing minimalist runners shoes compared to soldiers wearing traditional running shoes“. Obviously we are assuming that those wearing minimalist shoes were more likely to be a non-heel striker.

The other new study is a paper that is also to be presented at next weeks American College of Sports Medicine meeting, Warr et al assessed 342 soldiers and after assessing their foot strike pattern, 13% were classified as non-heel strikers. They found no differences between the injury rates and days lost from injury between the heel strikers and non-heel strikers.

On any hierarchy of the strength of evidence for ranking the importance of research results, all 6 of the above studies rank in the middle or closer to the bottom, mostly due to the retrospective nature of the designs of the studies. Some of them have other issues that affect their interpretation and applicability. For example, the almost elite level of the Daoud et al participants and the self-selected self-reported participants used in the Goss & Gross study – I single these two out as they are the ones most often mentioned in the cherry picking crankosphere blogosphere. For some reason you hardly ever see the Kleindiest and Walther studies mentioned, despite them having very large sample sizes of typical runners; but are also limited due to the retrospective nature of the design. The new larger studies by both Warr et al and  Grier et al confirm the results of the Kleindiest and Walther studies.

To me, the evidence is looking increasingly clear that there is probably no difference in injury rates between heel and and non-heel strikers despite all the rhetoric and propaganda. As I suggested here, there are probably different injuries with different foot strike patterns (which the Walther (2005) study reported).

POSTSCRIPT: Another new study has found no differences in injury rates

POSTSCRIPT 2: Differences in injury rates between…

As always, I go where the evidence takes me until convinced otherwise.

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3 Responses to Foot Strike Pattern and Injury Rates

  1. John Foster May 17, 2013 at 11:18 am #

    Another good post Craig. Just as the evidence that poor sitting posture causes generalised low back pain is poor so is the foot strike relationship to generalised lower limb injury. Simply too broad a group to get any meaningful causation relationships.
    Likewise we use good sitting posture as a tool in the treatment of low back pain just as we use a change in footstrike as a tool in the management of some injured runners. This of course does not equate to footstrike being the cause. One of many factors that is perhaps receiving too much attention in the blogosphere as you say.
    Perhaps heel strike needs to be further delineated into ‘extreme/moderate/mild’ categories, % range of dorsiflexion at foot strike or foot inclination angle in relationship to horizontal.
    Interestingly I’m seeing some runners with calf pain recently that have responded to changing from a heel strike to midfoot. Possibly the resultant changes further up the chain responsible.
    I go where my patients take me, the research helps but normally takes a few years to catch up.


  2. blaise Dubois May 18, 2013 at 2:00 pm #

    Hi Craig,
    Very nice to read you on another place that podiatry arena. Love your rigor about science.

    Some thought about your post (for more rigors… because we always analyze the literature with our own filter ☺ … I will criticize the 4 articles that your are not commenting as “extraordinary amount of press coverage” or “no one is giving much weight too”.

    1. Walther (2005): it seems to be published on a general medicine ‘non-peer review’ journal (laufverietzungen, orthopädieschhtechnik) written in German (very low in your hierarchy of the strength of evidence and not accessible for all)
    2. Kleindienst (2003): is this article published? (not available on Embased and Medline)? Is it published in a peer-review journal? Is Kleindienst works for adidas? Is the article written in german again? (you can answer to me only if the answer is NO to those questions)
    4. Grier and Warr are not publish yet… doesn’t mean it’s bad… just waiting for the complete data and reviewed by the peers (very low in your hierarchy of the strength of evidence… for the moment)

    To me, the evidence is just no conclusive… even if the there is a tendency to a decrease injury rates for non-heel strikers… And I agree that there is probably different type of injuries depending of the foot strike. (A good example is the chronic exertional anterior compartment syndrome. with the studies of Kurby-1983, Jerosh-1995 and Diebal-2012)


  3. Enric Martinez July 19, 2016 at 3:03 pm #

    Hello from the Future, this is 2016 😉

    Nice article.

    I assume that all sums up to these points:

    * It makes no sense to compare experienced runners with weekend warriors
    * The footstrike is highly variable and well trained runners will have less injuries using the strike they are training to use
    * The gear with which you will have less injury is the one you are used to train with

    The two latter sound like quoting from Dr. O. B. Vious, but something even scientists tend to forget in this regard is that training literally means “adapting your body to a specific movement pattern” and that training also implies a certain selective factor meaning that the athlete or trainer will select the gear, strike and training methods that deliver the best results and discard the rest so that after a certain time an experienced runner will be using the optimal combination of gait and gear.

    There will surely be advantages in using forefoot or midfoot strike (if there actually is a difference among these) for determined footing or it might be that a given type of strike would be better suited for the majority, but this is not up to me to say.

    On the other part, the injury rate among weekend warriors should be seen as result of many factors, not only gear and foot strike but of anything from weak core to lack of training volume… but this also pertains to Dr O.B. Vious famous studies 😉

    Kudos for the blog!!!

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