A Sports Medicine Look at Barefoot Running

By Michael Ross, MD, Sports Medicine Editor

The forefoot/midfoot strike has gained popularity recently among runners, triathletes and ultra-marathoners. While there is nothing new about it, barefoot running (and the oxymoronic “barefoot running shoes”) have regained popularity in large part due to Christopher McDougal’s book Born to Run.

In recent history, barefoot running was brought to the forefront of our attention by Abebe Bikila’s 1960 Olympic Marathon gold medal performance.

And then, Zola Budd, the South African teenage track runner turned British teen track runner from the 1984 Olympics, made an international spectacle of running barefoot during the 3,000 meter when she and Mary Decker of the US made contact and tangled feet. Decker hit the deck as Budd drifted back.

I have watched, paused, and rewound those videos multiple times and both Budd and Bikila used a combination of heel and forefoot strikes during their respective races. So what is it about forefoot running that has made it such a cult-like phenomenon?

In forefoot running technique, the base of the little toes of the foot strike the ground first. There is no heel strike and the foot doesn’t roll backwards onto the heel. Because there is no heel strike, there is no need to reach forward with the leg. Instead, one uses core strength to help lean forward slightly. The forward lean places the center of gravity over the feet.

A foot is most rigid when it is pointed down at the ankle and pressure is applied to the base of the little toes. Landing on a rigid foot makes the foot feel more springy. This is especially true if one is trying to prevent overpronation.

When running barefoot, athletes land in more plantarflexion at the ankle. This causes reduced impact and significantly shorter stride length along with higher stride frequency. There was also a shorter contact time with the ground (1). These changes in gait from a heel strike significantly reduced impact and decreased changes in the joints above the ankle as well. Try this experiment: jump up and down rolling from a flat foot up to your toes, into the air, and back down. When you land, let your knees absorb the impact and come to a stop. Repeat. Again. And again. Now try the same few jumps only on your toes. You might notice that the ankles absorbed most of the shock from the landing.

Perhaps the anticipated shock from foot strike is lessened with a forefoot strike. Hard landings, especially when unexpected, don’t let the muscles of the leg adapt, which can lead to increase impact forces in the leg (2). The detractors of cushion, medial support, and stability shoes will tell you that extra padding doesn’t let you “feel” the ground.

Unless you are running on exactly the same terrain and exactly the same surface at exactly the same pace, there cannot be a single perfect foot strike. By this logic, there is no single perfect shoe. Forefoot strike running can be done in any shoe. Even watching the barefoot running greats Bikila and Budd, they don’t always forefoot strike, so if you want to adopt a forefoot strike, you still might want to avoid Vibram Fivefingers or Newtons if you think you might stretch out your stride for the final stretch in your event.

Sounds good, right? After all, aren’t we spending millions of dollars on shoes that will cut down on our impact? Yes, we may be vilifying impact, but what does the role of impact play in efficiency and injury prevention. Most of the running injuries that I see in my sports medicine practice have very little to do with impact. The most common running injuries are patellofemoral pain and iliotibial band friction syndrome, both of which have much more to do with hip strength than with impact. Keep in mind that even Bikila had foot and knee injuries, which kept him from the 1968 Olympics.

Certain people, however, should consider a switch to forefoot strike. If you have had impact related injuries such as tibial, femoral or pelvic stress fractures, forefoot striking might be for you. Certain injuries such as plantar faciitis, Achilles tendonitis or foot stress fractures might not do as well with the rigid foot and forefoot strike associated with a barefoot running style.

To maintain the posture needed for forefoot striking, the core muscles, especially the muscles in the back of the calves, thighs, and hips, need to be activated. Many people cannot activate these muscles when running at slow speeds. As the speed picks up, the forward lean of the running technique takes over and the proper forefoot running technique is achieved. The problem for some is maintaining that higher speed. I have tested many people who might only be able to start with a forefoot strike and can only maintain forefoot striking for a brief period. Some even have a forefoot strike on one foot and a heel strike on the other. Proper training at the right intensity is important. One look at efficiency of a forefoot technique found it to be less efficient (more work for a given speed). This means that you have to be in better shape to keep the same speed over a given distance (3).

Due to the high demands of forefoot running on certain muscles, adequate strength and conditioning has to be in place before starting a barefoot program. Strength training includes bracing strength of the Achilles, hamstring strength, core strength and pelvic stabilizer strength. Specific exercises will be covered in a future article.

While barefoot running may not be for everyone, it is certainly worth a look for those with impact-related injuries. Because of the increased use of new muscles, specific strength and conditioning are necessary. To try running barefoot, you don’t need new shoes, just try running on a treadmill without shoes and keep your weight over your feet. Your feet will do a good job of keeping you in a barefoot stance.

(1) Squadrone R, Gallozzi C. Biomechanical and physiological comparison of barefoot and two shod conditions in experienced barefoot runners. J Sports Med Phys Fitness. 2009 Mar;49(1):6-13. Lieberman DE, Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature. 2010 Jan 28;463(7280):531-5.

(2) Boyer KA, Nigg BM. Muscle tuning during running: implications of an un-tuned landing. J Biomech Eng. 2006 Dec;128(6):815-22.

(3) Dallam GM et al. Effect of a global alteration of running technique on kinematics and economy. J Sports Sci. 2005 Jul;23(7):757-64.

Michael Ross, MD Dr. Micheal Ross is a sports medicine physician who has been treating endurance athletes for over a decade. He has been a team physician for numerous professional cycling teams. He also runs the Rothman Institute Performance Lab, a medical and scientific exercise testing and training facility in Bryn Mawr, Pennsylvania. He has written two books on training and sports medicine for endurance athletes as well as multiple scientific papers. He has been an invited speaker at USA cycling and consulted for several bicycle companies to provide the optimum fit. He is an avid triathlete himself who has qualified for short course triathlon nationals several times. When he is not at work or spending time with his family he can be found on the trails and the roads around Philadelphia. www.rothmaninstitute.com/physicians/michael-j-ross-md