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HAND-CRAFTED PHYSICAL THERAPY IN MIAMI
Bruce R. Wilk, P.T., O.C.S. Director
8720 N. Kendall Dr. Ste. 206
Miami, FL 33176
tel. 305.595.9425
 fax. 305.595.8492
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by

Bruce Wilk, PT, OCS
Christopher Jagessar, PT, OCS, ATC Sokunthea Nau, DPT
Jeffrey Stenback, PT, OCS Annmarie Garis, DPT
 


The novelty of running in minimalist shoes has been a growing trend in recent years. Some shoe companies make claims in the media and on their Web sites claiming that they “facilitate a natural, injury preventive running gait.”1 Most of these shoes offer significantly less support and are purported to alter the runner’s stride so that they run more “efficiently.” As a result of this widespread marketing towards minimalist shoes, many runners are purchasing these shoes in hopes of improving their running and eliminating their current running related injuries. Unfortunately, since many of these runners may already be injured or have existing altered running biomechanics, they may be causing or aggravating existing musculoskeletal impairments or biomechanical inefficiencies.

In our 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.

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.

Also noted 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 program.

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.

REFERENCES

  1. Newton Running. www.Newtonrunning.com. 2011. Accessed June 4, 2012.
  2. Superfeet, Inc. www.Superfeet.com/activity/running-walking.aspx. Accessed March 6, 2012

  3.  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.
  4. O’Connor FG, Wilder RP. Textbook of Running Medicine. New York, NY: McGraw-Hill; 2001:5.

  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.

  6. 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.

  7. Macera C, Pate R, Powell K, et al. Predicting lower extremity injuries among habitual runners. Arch Intern Med. 1989;149(11):2565-2568.

  8. 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.
E-mail: chris@wilkpt.com

Christopher Jagessar, PT, OCS, ATC1
Sokunthea Nau, DPT2
Jeffery T. Stenback, PT, OCS3
Annmarie Garis, DPT4
Bruce R. Wilk, PT, OCS5

1Physical Therapist, 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. 


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