clinic, we commonly see acute and often severe injuries
such as metatarsal stress fractures or navicular drop
correlating to minimalist shoe usage. Overuse injuries
such as tendonitis and various muscle strains of the
lower extremities have also been observed.REFERENCES
One of the popular minimalist shoe manufacturers is
Newton Running. The Newton Running1 shoe is designed to
promote a more “natural" way of running. In its attempt
to promote a natural landing, most of the company’s shoe
designs have a forefoot posting that encourages the
runner to land on their forefoot/midfoot. However, we
have observed clinically that the forefoot posting
creates a torsional fulcrum at the midfoot if the runner
isn’t biomechanically sound. The torsion appears to
occur most notably during the stance phase of the
runner’s gait. The midfoot of the minimalist shoe has a
space or an effective “gap” between the heel of the shoe
and the higher forefoot posting. As the runner naturally
moves through the pronation component during the stance
phase of gait, “torsion” or twisting occurs and the
midfoot collapses since, in this gap, there is no part
of the shoe making contact with the ground. The unstable
fulcrum at the midfoot combined with an underlying
weakness or muscle imbalance can predispose a runner to
an acute or repetitive stress injury. This torsion is
amplified when the increased ground reaction forces of
running are added.
A recent patient in our office illustrated this problem.
J.R. is a 35 y/o male referred to physical therapy with
complaints of severe pain in his left lateral shin. J.R.
is a consistent runner, having previously completed two
full marathons within the past 3 years. He reported that
his symptoms began during mile 22 of his last full
marathon. Although he finished the race, J.R. reported
that his pain became progressively worse after its
initial onset. When asked about any changes to his
training or racing methods, he mentioned that he decided
to run the race in the Newton minimalist shoes with
Superfeet orthoses2 in an attempt to improve his
previous marathon time and reduce his risk for injury.
J.R carefully followed Newton’s website tips on
“adjusting to your running shoes1” when he initially
transitioned into the new minimalist shoes. Prior to
this transition, J.R. was running in Nike stability3
shoes with Superfeet orthoses,2 which he had purchased
from the same store that later sold him the Newton shoes
with Superfeet orthoses. J.R. originally purchased the
stability shoes and orthoses after suffering an injury
10 months prior. At that time, after negative x-ray
results, he was diagnosed with plantar fasciitis. The
podiatrist’s prescribed treatment was simply sending
J.R. to this running store for Superfeet orthoses and a
new pair of shoes. The store sold him the Nike stability
shoes with Superfeet orthoses, and he reported having no
problems while running in the stability shoes.
Shoe inspection (his minimalist shoes) revealed
mechanical breakdown of the left shoe’s medial platform
and upper into pronation (Figure 1). No visible changes
or faults in the right shoe were observed. Current
examination of his orthoses revealed breakdown of the
medial side of the left orthotic at the arch.
was a “crack” in the orthotic that was present at the
platform where the most breakdown occurred (Figure 2).
This finding was consistent with the region of breakdown
described in the left shoe. There was no significant
breakdown of the right or left sides of the stability
shoe and there was no obvious medial deformity present
in the shoe itself.
Physical examination of J.R. revealed moderate edema
located in the left lateral ankle and foot. There was a
palpable deficit in the left peroneus longus tendon, 6
inches proximal to the left lateral malleolus with the
patient reporting a subjective pain level of 8/10. J.R.
denied that this deficit was present prior to his most
recent injury. These findings suggested a probable tear.
No additional diagnostic imaging was completed at that
time. He had a hypermobile subtalar joint toward
overpronation observed during weightbearing. J.R.
additionally reported difficulty with weight bearing
activities such as walking, standing, transitional
movements, as well as morning pain and stiffness getting
out of bed. He demonstrated an antalgic gait pattern and
was unable to functionally weight bear onto his first
ray while performing a heel raise.
There is existing data indicating that one of the
predictors of a future running injury is a prior running
injury within the past year.4 Moreover, the rate of
injury has been shown to be higher with minimalist
footwear in those runners who have transitioned from a
more supportive shoe5 and remains higher after their
transition period with sustained usage than runners not
using minimalist shoes.6 We postulated that he was
running asymptomatically while in the stability shoe
because he had the adequate medial support he needed to
manage his functional weakness. However, when
transitioning into the minimalist shoe, we felt that the
combination of this functional instability in his left
lower extremity combined with an unsupportive shoe, led
to the breakdown of the orthotic--which ultimately led
to his running related injury. Examination of this
patient’s equipment/footwear was crucial to his
assessment; guided treatment decisions, and contributed
to the successful return of this patient to his running
In addition to proper equipment, focus was placed on
correct running biomechanics to return the patient back
to their sport safely and to encourage independent
function. During the later stages of rehabilitation,
sports specific exercises including plyometrics and
stride development (eg, cadence and turnover) were also
important components. J.R. was instructed in a
return-to-training program as well as a graded
injury-specific exercise progression. Upon discharge,
J.R. was able to return to full function (including
running) and he subsequently ran his personal best at
his next half marathon. Addressing all of these issues
combined with immediately getting him out of minimalist
shoes, and into a more supportive shoe, was important in
effectively managing this case.
After J.R’s injury, Newton shoes recently released a
disclaimer on their website stating, “Pre-existing
conditions or injuries may mean our shoes are not right
for you. If you have an injury, a biomechanical issue,
an anomaly or a predisposition to a particular type of
injury, consult your physician, coach, or orthotics
supplier before using Newton shoes1.” This statement
alone excludes the majority of the running population
from safely running in Newton shoes. Injury rates are
higher for both runners who transition to minimalist
footwear5,6 and for runners with current injury or
injury within the last year.4,7 Thus, for a recently
injured runner, transitioning to Newton shoes only
multiplies risk factors.
New trends in athletic footwear frequently dominate the
marketplace and are often directed at the novice runner
or someone that suffers from current or previous running
injuries. However, in contrast, Newton’s recent website
disclaimer clarifies that Newton shoes are only for the
small percentage of runners who have not been injured
and are not at risk for injury. As physical therapists,
we should be aware of the growing trend in minimalist
shoes. It has been proposed that runner’s who have
“intact neuromuscular systems” can increase the strength
of their feet with the use of minimalist shoes.8 Those
runners trying the shoe should have at least three
consistent years of running experience and no injuries
within the past year because runners who do not meet
these criteria are more at risk for sustaining a new
injury.7 In addition, the runner must gradually
introduce the minimalist shoe into their training
program so that their body is able to adapt to the
decreased support these shoes offer. Minimalist shoes
may be appropriate for some runners or in specific
instances, but we believe they should NOT be marketed as
a blanket solution for the general runner. Certainly in
J.R.’s case, the minimalist shoe appears to have
amplified his predisposition to injury.
This case was seen at Orthopedic Rehabilitation
Specialists, an outpatient physical therapy clinic in
Miami, FL. At the time of the case, the patient, J.R.,
was under the care of Sokunthea Nau, DPT. We understand
that running injuries are multifactoral based on both
intrinsic and extrinsic factors. Although the change in
footwear may be related to the injury described in this
case, the authors cannot establish a cause-effect
relationship between footwear and running injury for
this patient. Therefore, the opinions or assertions
contained herein are the private views of the authors
and are not to be construed as official. However, as
musculoskeletal specialists, we must be able to identify
possible risk factors for injury to include: less than 3
years of running experience, a running injury within the
last year, and transitioning to minimalist footwear.
- Newton Running.
www.Newtonrunning.com. 2011. Accessed June 4, 2012.
Superfeet, Inc. www.Superfeet.com/activity/running-walking.aspx. Accessed March 6, 2012
- Nike, Inc. www.Nikerunning.nike.com/nikeos/p/nikeplus/en_US/commerce/men?hf=10002^4294909548&t=Men%27%20Stability%20Run.
Accessed March 6, 2012.
O’Connor FG, Wilder RP. Textbook of Running Medicine. New York, NY: McGraw-Hill; 2001:5.
Gutierrez GM, Olin E. Muscle Activity and Tibial Shock During the Initial Transition From Shod to Barefoot Running. Oral Presentation at the
23rd Congress of the International Society of Biomechanics (ISB), July 2011. Proceedings of the 23rd ISB Congress. Brussels, Belgium.
Leong R. The Effects of Footwear Habits of Long-Distance Runners on Running Related Injury: A Prospective Cohort. Running Training
Plan. http:www.runningtraining. Accessed March 6, 2012.
Macera C, Pate R, Powell K, et al. Predicting lower extremity injuries among habitual runners. Arch Intern Med. 1989;149(11):2565-2568.
Davis I. What can we learn from watching children run? J Am Med Athl Assoc. 2011;24 (3):7-8.
Address correspondence to:
Christopher Jagessar, 8720 North Kendall Drive Suite
206, Miami, FL 33176.
Christopher Jagessar, PT, OCS, ATC1
Sokunthea Nau, DPT2
Jeffery T. Stenback, PT, OCS3
Annmarie Garis, DPT4
Bruce R. Wilk, PT, OCS5
Orthopedic Rehabilitation Specialists, Miami, FL.
2 Physical Therapist, Orthopedic Rehabilitation
Specialists, Miami, FL.
3 Assistant Director/Physical Therapist, Orthopedic
Rehabilitation Specialists, Miami, FL.
4 Physical Therapist, Orthopedic Rehabilitation
Specialists, Miami, FL
5 Director/Physical Therapist, Orthopedic Rehabilitation
Specialists, Miami, FL.