Following a running-related injury (RRI),
patients often seek guidance on proper shoe
selection. It is vital for sports rehabilitation
clinicians to be able to identify and evaluate
patient need, offer recommendations, and isolate
defective or worn out shoes.
A safe and proper return to participation
begins with an appropriate pair of running shoes
and a sound training program. Choosing a shoe
free from defects and based on individual gait
analysis has afforded injured patients a faster
return to safe running.1
Gait Analysis in Shoe Selection
When
purchasing the ideal running shoe, patients
should begin by consulting with a specialty
running shoe store. Most specialty running shoe
stores routinely use video gait analysis on a
treadmill, to provide baseline information about
an individual's specific needs before
recommending any running shoes. Video gait
analysis is an effective way to observe and
analyze individual biomechanics, as an
evaluation of full gait is required to
adequately analyze the patient's foot and gait
pattern.2
Minimalist shoes and racing flats should be
used for the initial video gait analysis so the
shoe doesn't affect gait mechanics, such as
pronation.2,3 It is not safe for
patients to run barefoot on a treadmill; thus,
barefoot running should never be used for any
video gait analysis. Before taking the patient
on the treadmill, make sure all metatarsals of
the foot are sitting evenly on the shoe
platform, taking notice of the width of foot.
Any portion of the foot sagging over the edges
is a signal of an improper fit and can lead to
an inaccurate analysis, as well as discomfort.
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Elite high school and collegiate
athletes travel to Philadelphia every
April for the Penn Relays, the oldest
and largest track and field competition
in the United States. With technological
advances such as video gait analysis,
sports rehab clinicians are better
equipped to make training and equipment
decisions to keep these high-level
athletes healthy and injury free.
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During video gait analysis, look for
non-neutral gait patterns, and listen to the
sound of the foot strike. Once videotaped,
analyze the gait pattern in both slow motion and
at full speed to precisely evaluate any signs of
overpronation or supination. Evidence of
overpronation or supination, proven by video
gait analysis, can help the patient select a
shoe that works for their gait pattern. With a
significant amount of overpronation, the patient
will benefit from a more stable, supportive
shoe, classified in the stability category.
Limiting the amount of movement in the rearfoot
allows the patient to have maximum support upon
foot strike.
A study presenting rearfoot motion with
neutral shoes versus stability/motion control
shoes proved that a runner in a neutral shoe had
a 6.5-degree movement while the stability/motion
control was significantly less.4
These shoes come equipped with medial posting
and firmer materials built into the shoe to help
prevent the overpronation during foot strikes. A
patient who supinates will benefit from a
less-stable, more cushioned shoe, providing more
impact-resistant materials such as gel and air.
The salesperson at a specialty running shoe
store should know how to properly analyze gait
and must also be knowledgeable about a variety
of different shoes in a variety of brands. The
salesperson should attempt to fit as many shoes
as possible, keeping within the category
recommended for the patient. Once a few shoes
have been narrowed down, the patient should try
on the different shoes and focus on the comfort
and fit of the shoe.
Specifically, the fitter should observe how
the shoe moves when striking the ground, how the
rubber compresses on the foot, and the patient's
overall subjective comfort level. With the new
shoe, have the patient run on the treadmill, and
analyze gait mechanics during initial contact,
midstance and push-off.
Check whether the shoe is digging or rubbing
on any portion of the foot. A patient running
with too much support will present a clucking
sound upon foot strike, whereas a patient
running with too little support will present a
slapping sound upon foot strike. Most
importantly, ask the patient if the shoe feels
like it's a part of the foot. A well-fit shoe
will feel like a continuation of the foot.
Runners, historically, have used more
supportive shoes early in training and
progressed to lighter weight and less platform
later in training. This traditional concept of
running may work for seasoned athletes, but for
injury management, always go with more shoe, as
more support is necessary for safe, initial
return to participation.
Upon return to participation, the patient's
feet are reintroduced to body weight load.
Sudden body load increase can stress healing
muscles and bones. Load stress brought on by
overpronation is increased up to 200 percent;
thus, the control of initial pronation (support
shoes) is much more important in running shoe
design than cushioned shock absorption.5
Therefore, if a patient is nursing an injury,
more load support will likely increase safe
injury management.
Detecting Defective Running Shoes
Avoiding defective running shoes is critical
to preventing further injury. An athletic shoe
should be constructed so that its upper, midsole
and outer sole is firmly attached. Inflexible
shoes can cause calf muscles to overwork and can
contribute to the development of specific
injuries.6
Before recommending a shoe, check its
construction. The shoe should continuously be
glued together correctly at all locations. The
upper (mesh portion) should be glued straight
into the sole. The sole of the shoe should be
level to the surface it is resting on.7
Check for asymmetry from side to side on each
shoe. If the shoe can be rocked, then it may not
adequately support the foot from rolling
excessively when worn.
When using a shoe with air pockets or gel
pockets, check to see whether those materials
are still inflated. Sometimes, the support
technologies within the shoe tend to deflate,
thus leaving the shoe purposeless. A shoe should
have flexibility, with the flex occurring
specifically at the metatarsal heads, the widest
portion of the shoe (toe box).8
Furthermore, when choosing a running
specialty store, be sure that the shoe selection
is always current. An older model shoe that's
been discounted may not be the best choice
because some materials within the shoe, such as
gels and rubbers, do have a limited shelf life.
A safe return to running activities should
initially begin with some fitness walking with
full heel-to-toe motion, and progress to
gliding, which is flat-foot initial contact for
long, slow distance. The shoe should allow an
individual to move through a full gait
heel-to-toe motion. A forefoot gait pattern is
practiced and refined later with accelerations
during training and plyometric exercises.
Physical therapists, athletic trainers and
associated rehab personnel should consider the
kind of injury, extent of the injury, and
training level of each individual before
recommending a return to a training program.
Refining performance should focus on
biomechanical energy efficiency.
This applies to a precisely fitted shoe. Foot
strike energy should be returned at the right
location at the right time and a reduction of
energy is more important than return of energy.9
Reducing the amount of energy upon foot
strike for a patient returning to participation
thus allows the patient to safely return to
activity progressively through the correct
fitness regime.
Presenting ample knowledge on shoe
recommendations can greatly improve the outcomes
of injury management regimes. Provided with
accurate information, a patient suffering from a
RRI can safely and successfully return to
running.
References
1. Gabor, J. (2006). Computational
intelligence for movement sciences: Neural
networks and other emerging techniques. Ed.
Rezaul Begg. Hershey, PA: Idea Group Publishing.
2. Whittle, M. (2002). Gait analysis: An
introduction. Third edition.
3. Wilk, B. (2007). The Nike Free as a useful
tool for video gait analysis.
http://www.thefreelibrary.com/The+Nike+Free+as+a+useful+tool+for+video-gait+analysis-a0171020562
4. Cheung, T., Roy, H., Ng, Y., et al.
(2006). Efficacy of motion control shoes for
reducing excessive rearfoot motion in fatigued
runners.
5. Murphy, V. (2004). The efficacy of
subplantar cushioning in modulating ground
reaction force and total impulse in normal
walking gait.
http://www.medicalengineer.co.uk/pages/rehabilitation-engineering/gait-analysis.html
6. Denoth, J., & Stacoff, A. (1988). Running
injuries and running shoe construction:
Demonstration of possible correlations.
http://www.ncbi.nlm.nih.gov/pubmed/3242154.
7. Wilk, B. (2000). Defective running shoes
as a contributing factor in plantar fasciitis in
a triathlete.
http://www.ncbi.nlm.nih.gov/pubmed/10705593.
8. Pribut, S. (2009). Selecting and fitting a
running shoe.
http://drpribut.com/sports/spshoe_fit.html
9. Segesser, B., & Nigg, B. (1993).
Orthopedic and biomechanical concepts of sports
shoe construction.
http://www.ncbi.nlm.nih.gov/pubmed/7908458.
Bruce R. Wilk is director of Orthopedic
Rehabilitation Specialists, Miami, FL, president
of The Runner's High, and head coach of the
Miami Runners Club. Anthony R. Di Mercurio is
studying his physical therapy prerequisites and
is a sales associate at The Runner's High
