Going Bananas Over Shoes

I recently did a study for a shoe company where I was supposed to tell the anti-pronation shoes from the neutral shoes among four different shrouded shoes. It should have been a cinch for a biomechanics expert like me, right? I got all four shoes wrong...at least according to the company and their classifications of the pairs of shoes. A dart throwing chimpanzee would have scored better. Then again maybe I got them all correct and they need to monkey around to reclassify the shoes.

According to the company the stability shoes (their term for any shoe containing an "anti pronation device") were as such because of a medial post (their term for a heel midsole with harder rubber on the medial side of the shoe than the lateral). The problem is that fortunately such a "device" won't really work and limit pronation. I say fortunately because my clinical observations say less than one in ten people need heel contact pronation limited. It does not work because 99.9% of runners have contact with the ground on the lateral side of their foot. The center of gravity stays lateral till well after mid stance on most people. Then it shifts more medial to anywhere between the big toe and the 3rd toe at toe-off. The point is that the medial block is just 'along for the ride" and does not come into play. If such a gimick worked, there would be a lot of very hurt runners out there because supination is far more injurious than pronation.

Still follow me? If you do, you are doing better than the R & D person at the shoe company whose eyes glazed over when I mentioned this. So all shoes are really neutral shoes, right? Not quite. Many of the neutral shoes have extra cushioning because convention "wisdom" in the industry dictates this. Shock absorption and anti-pronation are the marketing talking points. Extra cushioning also hides a multitude of rearfoot to forefoot functional transition shortcomings. You could say it helps smooth out the ride. It also makes body parts zig when they should be zagging. The brain compensates by firing certain muscle groups eccentrically to dampen the motion and right the errant body part. In essence, it cosmetically glosses over the short term while putting extra strain on the said body parts long term. So midsoles that are too soft are like putting lipstick on your "piggies."

So, anti-pronation shoes do not really limit pronation and neutral shoes randomly affect foot function depending upon the durometer of the midsole rubber under your personal center of gravity axis lines. Running shoe classification is not a science. It is an art. It is an art to limit the random avenues in the search your proper running shoe. What this means is be careful to trust less the company classification of the shoe and trust more what past experience tells you. If a model works out for you after a few weeks of running, go out and buy a couple more pairs of that shoe before they discontinue the model. Finally, make one of those pair into your "Sherlock shoes.

If the shoe fits...

The funny thing is that if shoes met the individual needs of the runner in a better fashion, this whole shod versus unshod discussion would become a moot point. However, that is a whole other rant for another day.

Another day has finally arrived. So let me attempt to tackle a very complex issue in the most distilled form of an explantion.

My first training shoes I ever owned for running were purchased in my second year of running for 2 bucks (1969). For the first year, I used my regular sneakers. Those running shoes had a canvas upper, narrow heel, flimsy arch, and no cushioning. Such characteristics are the complete antithesis to running shoes today. Yet somehow, I managed to run injury free for the almost 2 years I ran in that model. The same was true for all of my teammates. There were “luxury” trainers available from Adidas or Pumas. But, most of our pennies were saved to buy the spikes needed to race on the cinder tracks we had in that era. Meanwhile, the road racing groundswell was in the making. Distance Running news became Runner’s World Magazine. Bill Rodgers and Frank Shorter were the pied piper icons to fuel the emerging running boom fire. In the late 70’s RW did their first comprehensive shoe review. A human performance lab did several physical characteristic tests. Based on this data, the shoes were ranked from one to five stars. The idea was innovative and with good intentions. But we all know that many times the road race to hell is paved with good intentions. Sales of 5 star shoes skyrocketed while excellent shoes that didn’t test well were ranked 1 or 2 stars and were suddenly discontinued. For example, one test in the study measured absorption of energy of a weight dropped onto the heel of a shoe. So, here is the classic en vitro versus en vivo scientific principle. Measurements in the test tube in the lab do not reflect what is happening in the real world. This only measures initial impact in the shoe and says nothing about the angular velocities and peak and sustained forces on tendons, muscles, bones and ligaments in the human body. Shoes that were not right for many people flourished and led to the nuclear arms race of which company could produce the biggest attenuation of the initial impact force.

Dr. Daniel Leiberman’s recent studies point out that heel strike causes an initial impact transient, a nearly instantaneous and large increase in force that occurs as the heel comes to a sudden stop upon impacting the ground. The shoe reduces the force by about 10% and slows the rate of loading considerably. This, in addition to distributing the impact force over a larger area of the rearfoot, makes it comfortable to exaggerate heel strike leading to the en vivo stress on the human body.

Shoe reviews do not shoulder all the blame. The consumer who is enthralled with the latest gimmick fuels the diversion away from what is really best for them. Back in the 60’s, Keds had the magic wedge which “make you run faster and jump higher.” It quickly became apparent to shoe companies that you put an untested gimmick (a few weeks use by a wear tester at best) on the market. The Nike “air” is classic example of this. It was sealed gas tubes enclosed in a polyurethane midsole. The Tailwind was a successful selling shoe even though instability injuries were rampant with the shoe. The Columbia attempted to address this instability by added a more stable EVA, but like the spaceship Columbia in its ad, it too, crashed and burned. It took several renditions of the air gizmo before the bugs were worked all. If the consumer wasn't so willing to be the long term ginea pig for an idea they like, gimmicks and gizmos would be an insignificant factor.

Running shoes are supposed to protect the foot. However, running shoes are also a business. They are mostly part of huge publicly traded companies whose concerns are market share, sales, net profits, free cash flow, and everything that goes along with a myopic shareholder quarterly report.

This adds pressure to have shoes on the minimum number of lasts to accommodate the maximum number of people. Many companies copy another company's best selling lasts. This leads to less variation among the brands and even less models to address the subtle genetic diversity in all the feet out there. Not only at the corporate level but also the retail level where stores have only so much capital to stock their shelves. Improper fit leads to abnormal function.

Now add to the fact that Sport Trend magazine did a survey study in the late 80's and found that 80% of the running shoes purchased will never even be used for running.

You can see reasons for wayward goals and distractions of the health quality of running shoes. This is why the barefoot running community knows that unshod feet often outperform the latest couple hundred dollar smart shoe.

The Great Red Hope

A recent experimental treatment for tendinosis was found to no more effective than injecting salt water.

The hopes of many were raised when the media put forth articles such as these:

http://www.nytimes.com/2009/02/17/sports/17blood.html?ref=health

http://www.nytimes.com/2009/08/20/health/nutrition/20best.html?_r=1&src=twt&twt=nytimesstyle

It sounds seductive to take extracts of the athlete's own blood and inject them into the injured area to heal an injured tendon. Most chronic tendon injuries are as a result of a complex process called tendinosis. So what is the cliff notes version of tendinosis? The suffix "osis" implies a pathology of chronic degeneration without inflammation. The main problem for someone with tendinosis is failed healing, not inflammation; tendinosis is an accumulation over time of microscopic injuries that don't heal properly. Although inflammation can be involved in the initial stages of the injury, it is the inability of the tendon to heal that perpetuates the pain and disability. Most of the pain associated with tendinosis probably comes not from inflammation but from other irritating biochemical substances associated with the injury. Biochemically, it is the replacement of injured tendon collagen with the wrong kind of collagen. Normal tendons and ligaments consist mostly of Type I collagen, with smaller amounts of Type III collagen. When you get tendinosis, some of your collagen is injured and breaks down. Your body tries to heal the tendon, but when you have chronic tendinosis your body doesn't repair the collagen properly. The tendon loses its spring like characteristics which triggers more abnormal forces in a degenerating vicious cycle.

I know of many a recent athlete that opted for this procedure, which is not covered by medical insurances, only to have found they wasted valuable time and money.

The results of this double blind study are discussed here:

The new study included 54 people with chronic Achilles tendinopathy who participated in an exercise program to stretch their tendon while contracting their calf muscle. The exercise program was coupled with either a PRP injection or a saline (dummy) injection. Researchers measured pain and activity levels using a standardized tool at baseline, 6, 12, and 24 weeks.
Although there was an improvement seen among individuals treated with PRP after 24 weeks, it was no different than what was seen among those who received the placebo injection.

http://www.webmd.com/fitness-exercise/news/20100112/new-achilles-tendon-treatment-falls-short-of-hype

So what is a poor injured athlete to do? Surgery does work but takes 1 to 3 years to get "back to form." Keep in mind that "form" is slower than the pre-surgery form. I find the best option is to start with off-loading the tendon. A special tape is applied every 3 to 5 days to reduce peak forces in the tendon. Varying amounts of eccentric strengthening exercises are also helpful. Cortisone type steroids are a complete no no for this problem. However some people gain benefit from injection of an extract form the Arnica Montana plant. Then identify the hidden causes the are overloading the tendon. This takes a thorough, analytical, and diligent sports medicine physician. If you could do it yourself, you wouldn't be at this level of chronic injury, now would you?

Fighting tendinosis is a complex war, not a single battle. There is no magical silver bullet. So use all the resources at your disposal and increase a victorious outcome.

Rest in Peace Larry Olsen

The sun sets on a kind soul
I have called my friend.
For what seems like forever,
and now it is.

They say running is a loner sport
but they are not runners
For if they were, they would know
that every excursion is a group run.

Our friends are there over our shoulder
to set the pace and keep us strong
to strive...to dream...to laugh...
to live...to run, today.

I now hear the hollow sounds
of my own steps in stride.
For a special one in thundering herd
is now more distant.

Ambling Barefoot

Barefoot running has been around for awhile, but did not hit the national radar screen until the best selling book Born to Run by Christopher McDougall put a new face upon barefoot running interest. You know things are reaching a critical mass on this issue when non-runners start to bring articles about this to me in my office. Minimalist equipment, such as the Nike Free, Tera Plana, and more recently the Vibram Five Fingers (a glove for the feet) are gaining fans and market share.

This past week I received the following position statement from my National Professional Society:

APMA Position Statement on Barefoot Running

It is a very non committal statement leaning against unshod running. Some of the academy members were more critical: "Most of my patients aren't world class runners," adds foot doctor Stephen Pribut, DPM of the Academy of Podiatric Sports Medicine. "It wouldn't make sense for them to risk getting twigs and glass in their feet. And I think some soft surfaces increase plantar fascia and Achilles problems. Of course, what doesn't kill you might make you stronger."

Running surface conditions that are too soft can pose a risk to the shod as well as the unshod runner. Barefoot running can benefit the weekend warrior as well as the world class runner because I know of no class of abilities who doesn't want to have a smaller number of injuries. I only hope Dr. Pribut was quoted out of context. I see less plantar fascia and Achilles problems when bare feet meet the turf.

My first experience with barefoot running was at an AAU developmental track meet in Paramus, NJ. I was speaking with World Class marathoner Tom Fleming. My shin was stiff after winning a 3 mile race and he suggested that I warm down barefoot on the grass. I did so, but for some reason, never incorporated this maneuver into my routine. Now fast forward about 35 years. I am invited to participate in a semi-private thread by National Distance Running hall of famer Patti Catalano Dillon. I am there no more than a week and the barefoot running questions from Camille Herron get put to the foot doctor. I didn't have many answers so I did what any objective inquisitive runner/physician would do. I experienced it. Four years later, it has become an important tool in my running bag of tricks.

For the record, here is how I do it. I do not run barefoot on the extremes of surfaces, no roads and no beaches. I just gradually build up the barefoot miles to about half of my run. I find the best place in the urban/suburban environment is on AstroTurf. The consistency is perfect for running. The fields are swept of objects often with a "Zamboni" type contraption. Ironic, isn't it? The best place this lover of scenic trails runs to amble au natural is on an artificial surface.

There are some very compelling arguments for going shoeless, or at least wearing the least amount of shoe possible.

You may develop a more natural a fluid of gait. Sometimes I am so fluid, running takes on a Zen like enjoyment. This can only be proven in a subjective fashion by actually trying some unshod running.

It is the belief of this author that the biomechanics of running is cleaner. There is less errant eccentric and postural muscle firing during the gait cycle. Tendons have in excess of 90 percent energy return. Mid soles of running shoes have considerably less energy return so they impair rather than enhance function. Aging of the shoe materials causes even more loss of support and energy return.

So my national society feels there is a dearth of studies, abstracts, and reviews
available on shod versus unshod. It took me all of one hour to find a bunch. Here are some highlights:

Wearers of expensive running shoes that were promoted as correcting pronation or providing more cushioning experienced a greater prevalence of these running-related injuries than wearers of less expensive shoes (Robbins and Gouw, 1991). In another study, expensive athletic shoes accounted for more than twice as many injuries as cheaper shoes, a fact that prompted Robbins and Waked (1997) to suggest that deceptive advertising of athletic footwear (e.g., "cushioning impact") may represent a public health hazard. Anthony (1987) reported that running shoes should be considered protective devices (from dangerous or painful objects) rather than corrective devices, as their capacity for shock absorption and control of over-pronation is limited.

Michael Warburton: Running barefoot is associated with a substantially lower prevalence of acute injuries of the ankle and chronic injuries of the lower leg in developing countries, but well-designed studies of the effects of barefoot and shod running on injury are lacking. Laboratory studies show that the energy cost of running is reduced by about 4% when the feet are no shod. In spite of these apparent benefits, barefoot running is rare in competition, and there are no published controlled trials of the effects of running barefoot on simulated or real competitive performance.

When you run barefoot, your body precisely engages your vision, your brain, the soles of your feet, and all the muscles, bones, tendons, and supporting structures of your feet and legs. They leap to red alert, and give you a high degree of protection from the varied pressures and forces of running.

On the other hand, when you run in socks, shoes, inserts, mid soles and out soles, your body's proprioceptive system loses a lot of input. "This has been called 'the perceptual illusion' of running shoes," says Warburton. "With shoes, your body switches off to a degree, and your reaction time decreases."

So what are the risks? There is obviously less protection of the running bare foot. Ironically, my only pedal puncture wound ever sustained happened while running with running shoes on my feet.

So my society wants something conclusive? You cannot do a double blind study on something like this so results will always have some level of bias.

Abebe Bikila famously won the Olympic Marathon after discarding the shoes given to him before the race by a show company. Most Ethiopians I have treated have a "boxy" shaped foot. I am sure that the shoe company made he gaffe of giving him a shoe made on a traditional last for a western foot. The misfit was resulting in discomfort so Bikila went back to the known quantity or running barefoot like he had trained in his homeland.

Running barefoot is a healthy alternative to running shod. The educated runner will encounter minimal risks and great benefits. The funny thing is that if shoes met the individual needs of the runner in a better fashion, this whole shod versus unshod discussion would become a moot point. However, that is a whole other rant for another day.

The path less traveled

"TWO roads diverged in a yellow wood,
And sorry I could not travel both
And be one traveler, long I stood
And looked down one as far as I could
To where it bent in the undergrowth"


One of life’s crossroads came in junior high school for me. My main extracurricular activity was band. I played in the band or at least was the source of the band conductor’s indigestion with my very mediocre performance. Only the best made Jazz band. My goal of saxophone in the Jazz band was just a pipe dream or should I say a reed dream. There was something about the blue note that struck a chord with me. My problem was the John Phillip Souza sour notes that blocked the way to that goal. I turned down the less traveled path of running that early spring over 40 years ago. My foot steps still grace that path.

Last week I went to the Cohasset by the sea Road Race. I cannot believe it has been 30 years of one race for me. It feels like I am living a remake of the movie Same Time Next Year. I guess life does imitate art. But, a good race has a way of drawing one back. The time of year kicks off my racing season (especially as I age and race less often). The course is beautiful. It goes by quaint inlets, spectacular ocean vistas, mansions of the rich and famous, and historical points of interest. The course is challenging. Challenge inspires my gumption more than a flat fast “PR” course. The race is well run year after year. Every turn is marked and every split is barked out loud, clear, and accurate. The post race festivities (food, times, awards, etc.) are prompt and efficient. Then there is the legacy effect. Each year insidiously adds to its momentum. It seems to add to the tall tail legend effect, as well. I noticed that I was being credited with “5 or 6 wins” when in fact it is more like 3. At this rate, I can expect to be credited with 42 overall wins when they run the 40th annual in 7 years.

About 1,500 runners lined up on this sunny but very breezy 57 degree day. While waiting for the race to start, someone tapped me on the shoulder and introduced himself. It turned out to be my paperboy from the early/mid 1980’s. I had given him a shirt I got from famed miler Steve Scott as part of his newspaper Christmas tip. I remember this young boy reacting like I had given him a leprechaun’s pot of gold. He went on to become quite a middle distance runner. I wonder if my gift had any influence on his path. He then says that he will be shortly entering the masters division. Now I just feel real old rather than philosophical.

I ran a time of 37:23, a respectable time for someone about to turn 55. I particularly enjoyed this years Cohasset by the sea 10K. I felt good. I also had the surreal experience of many past positive and memorable moments merging into one nostalgic point of time. I won the race three different times today. I was also top 5 a gazillion times more. I ran mid 31 minutes like I did in my heyday. My picture crossing the finish line graced the cover of the Cohasset phone book afterwards. It was 90 degrees. It was 33. It was raining cats and dogs. There were small dogs flying off the ground (one year a small dog not on a leash dashed out from the narrow funnel of people right at the finish line. The race director hooked it with his foot a half stride in front of me barreling down the chute, sending it back into the crowd. All I saw was the poor pooch come from the bottom of my field of vision and take off like superdog out the upper right of my field of vision. Dog was startled but apparently unhurt. The same was true for yours truly).

So, I look forward to next year at my annual rite of spring, the Cohasset by the Sea Road Race and hopefully many more.

I topped the day off by going to a monthly jazz concert in Weymouth. Don Altobello and his group put on a fine show at Hajjar’s restaurant. It is stellar music of the style I always wanted to play. For a couple hours, the musical idioms help me slip into a musical bliss. Time again becomes non linear. I revisit that fateful divergence on my life’s path all over again, one that has made all the difference.

Ask Dr Bob (#3)

A reader writes: A friend of mine said I could be nailed by the USTAF for drinking Brigham Tea. It's just an energizing tea I buy in my local health food store. I say he's the one who's high for thinking I can be nailed for tea from a health food store.

Drugs, Sex, and Rock 0' Roll

Dear DSRR,

You can't get no satisfaction from me.

Your pal's right. I hope you didn't have a big bet riding on this one. Brigham Tea contains Ma Huang, which is Chinese Ephedra. It is a natural source of Ephedrine. If you drink that stuff before a USTAF event and you are a USTAF member, you can be subjected to a random drug test. It is not just my imagination getting in the way. The Ephedrine will show up on the test and put you in the banned in Boston. (and everywhere else) ranks along with Mary Decker- Tabb-etc-Slaney. While you're riding out your suspension in the Penalty Box, maybe you can meet her. She must be due for another hubby soon. Then she could become Mary-etc-Drugs, Sex and Rock '0 Roll. One consolation will be you be having fun, fun, fun after the USTAF takes your T-card away.

Ephedrine is not only illegal in organized running, it is also dangerous. Several heart failure deaths in the Boston-metro area have been attributed to Ma Huang in recent years. Now that's a stairway to heaven! Ma Huang is also the main ingredient in Mormons Tea,. Miners Tea, Bishops Tea, Teamster Tea, (so that's how they got rid of Jimmy Hoffa), and Squaw Tea. Similar (and also banned), substances are found in over the counter cold preparations. Some examples are Actifed, Drixoral, Dimetapp, Cantac, Allerest, Vicks Inhaler, and the beat goes on! Read labels! Phenylephrine, Phenylpropanolamine, Psuedoephedrine, Propylhexedrine, and Desoxyephedrine will all have you doing the Jailhouse rock. So, if your cold preparation contains any of these, you will be left out in the cold by the USTAF. You don't have to be on Cloud 9 to get banned from the long and winding road. Choosing a cold preparation you can use will be like stepping on eggs ... but its far better than UST AF getting into regulating Steppenwolf. Please don't ban my devil with the blue dress on. For if they start to regulate sex and rock 'n roll, we'll all become drifters from the sport.

Dr Bob (and the medicine show)