The long-term effect of minimalist shoes on running performance and injury: design of a randomised controlled trial

Running shoes for preventing lower limb running injuries in adults

BACKGROUND

Lower-limb running injuries are common. Running shoes have been proposed as one means of reducing injury risk. However, there is uncertainty as to how effective running shoes are for the prevention of injury. It is also unclear how the effects of different characteristics of running shoes prevent injury.

OBJECTIVES

To assess the effects (benefits and harms) of running shoes for preventing lower-limb running injuries in adult runners.

SEARCH METHODS

We searched the following databases: CENTRAL, MEDLINE, Embase, AMED, CINAHL Plus and SPORTDiscus plus trial registers WHO ICTRP and ClinicalTrials.gov. We also searched additional sources for published and unpublished trials. The date of the search was June 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs involving runners or military personnel in basic training that either compared a) a running shoe with a non-running shoe; b) different types of running shoes (minimalist, neutral/cushioned, motion control, stability, soft midsole, hard midsole); or c) footwear recommended and selected on foot posture versus footwear not recommended and not selected on foot posture for preventing lower-limb running injuries. Our primary outcomes were number of people sustaining a lower-limb running injury and number of lower-limb running injuries. Our secondary outcomes were number of runners who failed to return to running or their previous level of running, runner satisfaction with footwear, adverse events other than musculoskeletal injuries, and number of runners requiring hospital admission or surgery, or both, for musculoskeletal injury or adverse event.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility and performed data extraction and risk of bias assessment. The certainty of the included evidence was assessed using GRADE methodology.

MAIN RESULTS

We included 12 trials in the analysis which included a total of 11,240 participants, in trials that lasted from 6 to 26 weeks and were carried out in North America, Europe, Australia and South Africa. Most of the evidence was low or very low certainty as it was not possible to blind runners to their allocated running shoe, there was variation in the definition of an injury and characteristics of footwear, and there were too few studies for most comparisons. We did not find any trials that compared running shoes with non-running shoes. Neutral/cushioned versus minimalist (5 studies, 766 participants) Neutral/cushioned shoes may make little or no difference to the number of runners sustaining a lower-limb running injuries when compared with minimalist shoes (low-certainty evidence) (risk ratio (RR) 0.77, 95% confidence interval (CI) 0.59 to 1.01). One trial reported that 67% and 92% of runners were satisfied with their neutral/cushioned or minimalist running shoes, respectively (RR 0.73, 95% CI 0.47 to 1.12). Another trial reported mean satisfaction scores ranged from 4.0 to 4.3 in the neutral/ cushioned group and 3.6 to 3.9 in the minimalist running shoe group out of a total of 5. Hence neutral/cushioned running shoes may make little or no difference to runner satisfaction with footwear (low-certainty evidence). Motion control versus neutral / cushioned (2 studies, 421 participants) It is uncertain whether or not motion control shoes reduce the number of runners sustaining a lower-limb running injuries when compared with neutral / cushioned shoes because the quality of the evidence has been assessed as very low certainty (RR 0.92, 95% CI 0.30 to 2.81). Soft midsole versus hard midsole (2 studies, 1095 participants) Soft midsole shoes may make little or no difference to the number of runners sustaining a lower-limb running injuries when compared with hard midsole shoes (low-certainty of evidence) (RR 0.82, 95% CI 0.61 to 1.10). Stability versus neutral / cushioned (1 study, 57 participants) It is uncertain whether or not stability shoes reduce the number of runners sustaining a lower-limb running injuries when compared with neutral/cushioned shoes because the quality of the evidence has been assessed as very low certainty (RR 0.49, 95% CI 0.18 to 1.31). Motion control versus stability (1 study, 56 participants) It is uncertain whether or not motion control shoes reduce the number of runners sustaining a lower-limb running injuries when compared with stability shoes because the quality of the evidence has been assessed as very low certainty (RR 3.47, 95% CI 1.43 to 8.40). Running shoes prescribed and selected on foot posture (3 studies, 7203 participants) There was no evidence that running shoes prescribed based on static foot posture reduced the number of injuries compared with those who received a shoe not prescribed based on foot posture in military recruits (Rate Ratio 1.03, 95% CI 0.94 to 1.13). Subgroup analysis confirmed these findings were consistent between males and females. Therefore, prescribing running shoes and selecting on foot posture probably makes little or no difference to lower-limb running injuries (moderate-certainty evidence). Data were not available for all other review outcomes.

AUTHORS' CONCLUSIONS

Most evidence demonstrates no reduction in lower-limb running injuries in adults when comparing different types of running shoes. Overall, the certainty of the evidence determining whether different types of running shoes influence running injury rates was very low to low, and as such we are uncertain as to the true effects of different types of running shoes upon injury rates. There is no evidence that prescribing footwear based on foot type reduces running-related lower-limb injures in adults. The evidence for this comparison was rated as moderate and as such we can have more certainty when interpreting these findings. However, all three trials included in this comparison used military populations and as such the findings may differ in recreational runners.  Future researchers should develop a consensus definition of running shoe design to help standardise classification. The definition of a running injury should also be used consistently and confirmed via health practitioners. More researchers should consider a RCT design to increase the evidence in this area. Lastly, future work should look to explore the influence of different types or running shoes upon injury rates in specific subgroups.

The Impact of Functional Overreaching on Post-exercise Parasympathetic Reactivation in Runners

While post-exercise heart rate (HR) variability (HRV) has been shown to increase in response to training leading to improvements in performance, the effect of training leading to decrements in performance (i.e., overreaching) on this parameter has been largely ignored. This study evaluated the effect of heavy training leading to performance decrements on sub-maximal post-exercise HRV. Running performance [5 km treadmill time-trial (5TTT)], post-exercise HRV [root-mean-square difference of successive normal R-R intervals (RMSSD)] and measures of subjective training tolerance (Daily Analysis of Life Demands for Athletes "worse than normal" scores) were assessed in 11 male runners following 1 week of light training (LT), 2 weeks of heavy training (HT) and a 10 day taper (T). Post-exercise RMSSD was assessed following 5 min of running exercise at an individualised speed eliciting 85% of peak HR. Time to complete 5TTT likely increased following HT (ES = 0.14 ± 0.03; p < 0.001), and then almost certainly decreased following T (ES = -0.30 ± 0.07; p < 0.001). Subjective training tolerance worsened after HT (ES = -2.54 ± 0.62; p = 0.001) and improved after T (ES = 2.16 ± 0.64; p = 0.004). In comparison to LT, post-exercise RMSSD likely increased at HT (ES = 0.65 ± 0.55; p = 0.06), and likely decreased at T (ES = -0.69 ± 0.45; p = 0.02). A moderate within-subject correlation was found between 5TTT and post-exercise RMSSD (r = 0.47 ± 0.36; p = 0.03). Increased post-exercise RMSSD following HT demonstrated heightened post-exercise parasympathetic modulation in functionally overreached athletes. Heightened post-exercise RMSSD in this context appears paradoxical given this parameter also increases in response to improvements in performance. Thus, additional measures such as subjective training tolerance are required to interpret changes in post-exercise RMSSD.

Optimization of Maximal Rate of Heart Rate Increase Assessment in Runners

PURPOSE

Correlations between fatigue-induced changes in exercise performance and maximal rate of heart rate (HR) increase (rHRI) may be affected by exercise intensity during assessment. This study evaluated the sensitivity of rHRI for tracking performance when assessed at varying exercise intensities.

METHOD

Performance (time to complete a 5-km treadmill time-trial [5TTT]) and rHRI were assessed in 15 male runners following 1 week of light training, 2 weeks of heavy training (HT), and a 10-day taper (T). Maximal rate of HR increase (measured in bpm·s^-1) was the first derivative maximum of a sigmoidal curve fit to HR data recorded during 5 min of running at 8 km·h^-1 (rHRI_8km·h^-1), and during subsequent transition to 13 km·h^-1 (rHRI_8-13km·h^-1) for a further 5 min.

RESULTS

Time to complete a 5-km treadmill time-trial was likely slower following HT (effect size ± 90% confidence interval = 0.16 ± 0.06), and almost certainly faster following T (-0.34 ± 0.08). Maximal rate of HR increase during 5 min of running at 8 km·h^-1 and rHRI_8-13km·h^-1 were unchanged following HT and likely increased following T (0.77 ± 0.45 and 0.66 ± 0.62, respectively). A moderate within-individual correlation was found between 5TTT and rHRI_8km·h^-1 (r value ± 90% confidence interval = -.35 ± .32). However, in a subgroup of athletes (n = 7) who were almost certainly slower to complete the 5TTT (4.22 ± 0.88), larger correlations were found between the 5TTT and rHRI_8km·h^-1 (r = -.84 ± .22) and rHRI_8-13km·h^-1 (r = -.52 ± .41). Steady-state HR during rHRI assessment in this group was very likely greater than in the faster subgroup (≥ 1.34 ± 0.86).

CONCLUSION(S)

The 5TTT performance was tracked by both rHRI_8km·h^-1 and rHRI_8-13km·h^-1. Correlations between rHRI and performance were stronger in a subgroup of athletes who exhibited a slower 5TTT. Individualized workloads during rHRI assessment may be required to account for varying levels of physical conditioning.

Effects of Footwear and Fatigue on Running Economy and Biomechanics in Trail Runners

PURPOSE

This study aimed to examine the effects of footwear and neuromuscular fatigue induced by short distance trail running (TR) on running economy (RE) and biomechanics in well-trained and traditionally shod runners.

METHODS

RE, vertical and leg stiffness (Kvert and Kleg), as well as foot strike angle were measured from two 5-min treadmill running stages performed at a speed of 2.5 (with 10% grade, uphill running) and 2.77 m·s (level running) before and after an 18.4-km TR exercise (approximately 90% of maximal heart rate) in runners wearing minimalist shoes (MS), MS plus added mass (MSm), or traditional shoes (TS). Maximal voluntary contraction torque of knee extensors and perceived muscle pain were also evaluated before and after TR.

RESULTS

Maximal voluntary contraction values decreased after TR in all footwear conditions (P < 0.001), indicating the occurrence of neuromuscular fatigue. In the nonfatigued condition, runners exhibited a better RE only during level running in MS and MSm (i.e., combined effects of shoe mass and midsole geometry), in association with significant decreases in foot strike angle (P < 0.05). However, no significant difference in RE was observed between shod conditions after TR during either uphill or level running. Decreases in both Kvert/Kleg and foot strike angle were more pronounced during running in MS and MSm (P < 0.05) compared with TS, whatever the period. Calf pain increased after TR when wearing MS and MSm compared with TS (P < 0.05).

CONCLUSIONS

These findings indicated specific alterations in RE and biomechanics over time during the MS and MSm conditions compared with the TS condition. Future studies are warranted to evaluate the relationship between RE and footwear with fatigue in experienced minimally shod runners.

Six-week transition to minimalist shoes improves running economy and time-trial performance

OBJECTIVES

This study investigated if gradually introducing runners to minimalist shoes during training improved running economy and time-trial performance compared to training in conventional shoes. Changes in stride rate, stride length, footfall pattern and ankle plantar-flexor strength were also investigated.

DESIGN

Randomised parallel intervention trial.

METHODS

61 trained runners gradually increased the amount of running performed in either minimalist (n=31) or conventional (n=30) shoes during a six-week standardised training program. 5-km time-trial performance, running economy, ankle plantar-flexor strength, footfall pattern, stride rate and length were assessed in the allocated shoes at baseline and after training. Footfall pattern was determined from the time differential between rearfoot and forefoot (TD_R-F) pressure sensors.

RESULTS

The minimalist shoe group improved time-trial performance (effect size (ES): 0.24; 95% confidence interval (CI): 0.01, 0.48; p=0.046) and running economy (ES 0.48; 95%CI: 0.22, 0.74; p<0.001) more than the conventional shoe group. There were no minimalist shoe training effects on ankle plantar-flexor concentric (ES: 0.11; 95%CI: -0.18, 0.41; p=0.45), isometric (ES: 0.23; 95%CI: -0.17, 0.64; p=0.25), or eccentric strength (ES: 0.24; 95%CI: -0.17, 0.65; p=0.24). Minimalist shoes caused large reductions in TD_R-F (ES: 1.03; 95%CI: 0.65, 1.40; p<0.001) but only two runners changed to a forefoot footfall. Minimalist shoes had no effect on stride rate (ES: 0.04; 95%CI: -0.08, 0.16; p=0.53) or length (ES: 0.06; 95%CI: -0.06, 0.18; p=0.35).

CONCLUSIONS

Gradually introducing minimalist shoes over a six-week training block is an effective method for improving running economy and performance in trained runners.

Body Mass and Weekly Training Distance Influence the Pain and Injuries Experienced by Runners Using Minimalist Shoes: A Randomized Controlled Trial

BACKGROUND

Minimalist shoes have been popularized as a safe alternative to conventional running shoes. However, a paucity of research is available investigating the longer-term safety of minimalist shoes.

PURPOSE

To compare running-related pain and injury between minimalist and conventional shoes in trained runners and to investigate interactions between shoe type, body mass, and weekly training distance.

STUDY DESIGN

Randomized clinical trial; Level of evidence, 2.

METHODS

Sixty-one trained, habitual rearfoot footfall runners (mean ± SD: body mass, 74.6 ± 9.3 kg; weekly training distance, 25 ± 14 km) were randomly allocated to either minimalist or conventional shoes. Runners gradually increased the time spent running in their allocated shoes over 26 weeks. Running-related pain intensity was measured weekly by use of 100-mm visual analog scales. Time to first running-related injury was also assessed.

RESULTS

Interactions were found between shoe type and weekly training distance for weekly running-related pain; greater pain was experienced with minimalist shoes ( P < .05), and clinically meaningful increases (>10 mm) were noted when the weekly training distance was more than 35 km/wk. Eleven of 30 runners sustained an injury in conventional shoes compared with 16 of 31 runners in minimalist shoes (hazard ratio, 1.64; 95% confidence interval, 0.63-4.27; P = .31). A shoe × body mass interaction was found for time to first running-related injury ( P = .01). For runners using minimalist shoes, relative to runners using conventional shoes, the risk of sustaining an injury became more likely with increasing body mass above 71.4 kg, and the risk was moderately increased (hazard ratio, 2.00; 95% confidence interval, 1.10-3.66; P = .02) for runners using minimalist shoes who had a body mass of 85.7 kg.

CONCLUSIONS

Runners should limit weekly training distance in minimalist shoes to avoid running-related pain. Heavier runners are at greater risk of injury when running in minimalist shoes. Registration: Australian New Zealand Clinical Trials Registry (ACTRN12613000642785).

Loading rate increases during barefoot running in habitually shod runners: Individual responses to an unfamiliar condition

The purpose of this study was to examine the effect of barefoot running on initial loading rate (LR), lower extremity joint kinematics and kinetics, and neuromuscular control in habitually shod runners with an emphasis on the individual response to this unfamiliar condition. Kinematics and ground reaction force data were collected from 51 habitually shod runners during overground running in a barefoot and shod condition. Joint kinetics and stiffness were calculated with inverse dynamics. Inter-individual initial LR variability was explored by separating individuals by a barefoot/shod ratio to determine acute responders/non-responders. Mean initial LR was 54.1% greater in the barefoot when compared to the shod condition. Differences between acute responders/non-responders were found at peak and initial contact sagittal ankle angle and at initial ground contact. Correlations were found between barefoot sagittal ankle angle at initial ground contact and barefoot initial LR. A large variability in biomechanical responses to an acute exposure to barefoot running was found. A large intra-individual variability was found in initial LR but not ankle plantar-dorsiflexion between footwear conditions. A majority of habitually shod runners do not exhibit previously reported benefits in terms of reduced initial LRs when barefoot. Lastly, runners who increased LR when barefoot reduced LRs when wearing shoes to levels similar seen in habitually barefoot runners who do adopt a forefoot-landing pattern, despite increased dorsiflexion.