Barefoot Running Injuries

In the last few years, a new wave of runners has taken to the streets, sidewalks, and competitive races…they are the "barefoot runners". This style of running, as the name implies, means the athlete runs barefoot or with minimal heel cushioned running shoes, the most popular being the Vibrams Five Fingers (or VFF). The theory behind this style of running, first introduced in a study by Daniel Lieberman Ph.D., director of the Harvard Skeletal Biology Lab, is that it results in a motion that is more biomechanically sound or “natural”. The foot strikes the ground closer to the midfoot rather than striking at the heel, which is the case when wearing traditional heavy heel cushioned running shoes. This is felt to decrease the sudden, large impact sustained by the heel that usually occurs. The great debate goes on as to the optimal running style, with studies showing support both for and against the barefoot running stride. However, a concern among medical professionals is the apparent increased risk of injury associated with barefoot running and its continued escalation in popularity throughout the running world. 

Reasons for injury associated with barefoot running are not clear cut, but there appear to be a few identifiable mechanisms seen by physicians that are bearing out as the fad moves forward. Many runners attempting to transition simply do so too quickly, instead of in a slow, progressive fashion. They also don’t receive instruction on appropriate stride length (worse if too long) or mechanics. In addition, some make a mistake by seeking to change to the barefoot running stride while retaining their traditional shoes, which is not biomechanically sound. A certain population of runners, those with biomechanically disadvantaged feet, really have no business even entertaining barefoot running. Those are runners with forefoot instability or hypermobility, overpronation, and even excessive supination. Research out of Germany by Weist R, et al., as published in the American Journal of Sports Medicine, has also pointed out susceptibility to stress fracture, which is due to the alterations in forefoot loading seen during fatigued running. A state of running that is reached by most runners if they are doing half-marathon or marathon distances. 

Of the injuries seen with barefoot running, which include plantar fasciitis, Achilles and posterior tibial tendinopathy, and metatarsal stress fracture, posterior tibial tendinitis seems to be the least recognized and least understood by the general public. If left untreated it can cause you and your foot significant problems in the near and distant future. The posterior tibial tendon (PTT) is one of the most important tendons of the foot because it supports the arch, the arch that provides the shock absorption and tension needed for the foot to work properly with each step. The PTT arises in the calf, courses down behind the inside of the ankle (medial malleolus), and eventually attaches to the navicular bone in the instep, or arch of the foot. During the barefoot running stride the PTT experiences more strain on a repetitive basis.  This predisposes the PTT to an overuse injury with chronic inflammation, weakness, and dysfunction. If ignored, this can lead to the progressive collapse of the arch, and development of a permanent flatfoot deformity. A condition such as an end-stage acquired flat foot would be catastrophic to any running career.

Barefoot running should be approached with extreme caution and several factors must be taken into account if you’re going to entertain the idea. Just remember, it’s not for everyone if you’ve been told you have a high arch/cavus foot/extreme supinator, have a significant flatfoot/extreme overpronator, or have hypermobile joints (i.e. double-jointed, highly flexible) barefoot running would be less than ideal. Start out extremely slow by just walking barefoot on hard surfaces for 2-3 weeks. Follow this by running very short distances (no more than ¼ mile) once a day for 2 weeks. Increase your distance by maybe 10% per week thereafter. During this time find someone knowledgeable about barefoot running to serve as an “instructor” to you. 

It is vital to ensure you have good form with gentle, compliant landings and appropriate stride lengths. Stretching of your calf muscles and hamstrings will help promote flexibility and prevent stiffness or contracture, which contribute to injury. Most importantly, however, listen to your feet! If you begin feeling pain or persistent discomfort backtrack to the previous level of training and/or institute the traditional RICE (rest, ice, compression, elevation) protocol along with a short course of anti-inflammatories (aleve, ibuprofen). If symptoms continue with attempted barefoot running despite the above-stated measures this is likely an indication that barefoot running is not for you. Evaluation from an appropriately trained medical professional should be sought out to prevent any further detrimental progression of the condition.