Avoid Injury: Make Slow Transition to Barefoot-style Running Shoes

Screen shot 2013-03-21 at 9.33.51 PMBarefoot running is back in the news. Or rather barefoot-style running shoes. It’s the kind of “news story” that has “legs”. Yet the media angle is often misleading. I will quote from the first sentence of the story that appeared on the International Business Times website earlier this week: “A recent study seems to indicate that popular minimalist running shoes like Vibram FiveFingers, designed to encourage a barefoot running-style gait, are more likely to lead to bone injury.”

That new study “Foot Bone Marrow Edema after 10-week Transition to Minimalist Running Shoes” first appeared in the February 2013 issue of Medicine & Science in Sports & Exercise.  In the small, short-duration study, researchers from Brigham Young University divided young (average age 26) recreational runners (average weekly mileage of 15-30) into two groups. These runners were all running in traditional shoes with no prior experience in Vibram FiveFingers (and we assume barefoot or other true minimalist shoe) and none had significant injury in the six months before the study.  The first group continued their normal training in their conventional running shoes. The other group continued their normal training and added some of their running in Vibram FiveFingers.

A Runner’s World online article then soon appeared with this boldly provocative title: Study: Vibram FiveFingers Lead to Greater Risk of Foot Bone Injury.  A smaller font with no bold subtitle appeared: More evidence supporting a gradual transition to barefoot-style shoes. I agree with the subtitle.

As a background and as followers of the Natural Running Center already know, I am a physician, minimalist runner, and own a running shoe store (Two Rivers Treads) selling only minimal drop shoes.  In our small store in the small town of Shepherdstown, West Virginia, we have transitioned thousands of runners into flat footwear safely over the last three  years.  For most runners who have years in traditional shoes it takes months , even years , to be able to do the majority of running in FiveFingers.  We have a safe transition page on our store website. Other Natural Running Center store partners offer the same kind of information and cautionary advice with all their customers: transition to minimalism takes time, and the actual duration depends on a case-by-case basis.

No runner should be advised to run in FiveFingers unless an assessment of strength and mobility is performed and a focus is turned to improving  form.  If you do not have a skilled person to assist you.

Some important points to consider before agreeing with the Runner’s World main title that FiveFingers lead to injury.
•    First, shoes do not cause injury.  Running causes running injury.
•    The attrition rate of the study was 7 out of 36 (19%).  This is high for a small study.
•    From the article: “some subjects stopped logging their runs prior to the 10th week of training and 4 of the 19 Vibram subjects did not document their training at all.”  So we have no clear idea how these runners were transitioning.
•    From the article: “Although the original intention of the study design was for all subjects to have completely transitioned to VFF running shoes by the end of the 10 weeks of training, this did not happen for the majority of subjects.”  In my opinion, no coach or advocate of minimalism would ever suggest a runner completely transition to FiveFingers in 10 weeks if coming out of a traditional shoe.
•    From the article: “Seven subjects ran their maximum mileage in VFF prior to or during week 4.” This is called Vibram Exuberance syndrome (thank you Barefoot KenBob for this term) . Likely these runners felt a decreased effort or increased pleasure in running but their bones may not have made full adaptation.
•    The weekly mileage of the groups differ. The traditional group run more with no explanation. Maybe they were training more even before the transition? Maybe they where less limited? There is no information  about the group comparison before the study start (mileage, years of run, more detailed histories or assessments of strength/function).
•    From the article:  “the two individuals that suffered stress fractures reported perceived pain scores of 2 and 4 out of 10 during running, while some other runners without injury reported higher pain levels.”  An important unknown here is what level of edema is a positive adaptation vs. overuse.  Bones will adapt if the stimulus is gradual. While we all agree that overload on an unadapted tissue contributes to injury, lower levels of edema can also signal active remodeling  and may not be a sign of injury but rather bony adaptation.
•    The transition protocol used in this study was modeled from suggestions for transitioning to VFF published on the Vibram FiveFingers website in January 2011. The suggestions on the website have changed since then based on Vibram’s concern for healthier running and activity in their footwear.  Vibram FiveFingers was not marketed or advertised as running shoes in the early years and runners started discovering them and on their own made the change with little guidance.  With the assistance of an expert panel, Vibram created a state-of-the-art education site in early 2012.  The runners in this study followed none of the barefoot training as far as we can tell.  Most of the barefoot training occurs apart from the running. http://www.vibramfivefingers.com/education/why_barefoot_works.htm

A few thoughts before we draw any real conclusions from this small study.

•    If you ask a traditional shod runner to go straight into running in minimal footwear, without strengthening the muscles of the foot or addressing form, you are asking for an injury.  Traditional shoes with support and heel elevation can decondition the foot and promote muscle imbalance.  The foot must be retrained and the protocol did nothing to assist foot retraining.  These runners did not follow the 10% rule in increasing mileage either.
•    The study shows that there is a training stimulus to the bone if you wear FiveFingers and no training stimulus to the bone if you wear normal running shoes.  Runners in traditional shoes get stress fractures frequently.  If a training stimulus is above the capacity to adapt, the tissue will break down. If the training stimulus is correct, the bone will strengthen. If any tissue takes excessive loads, or no rest days, I would expect to see an injury with accompanying  inflammatory markers such as high grades of edema.
•    A 10-week study of less than 20 runners in each group with close to 20% drop out and poorly documented logs?  This should say enough.
•    The title of the Runner’s World article is misleading.  Wearing Vibrams or any minimalist shoe is not the cause of injury.  It is the hurried transition out of traditional running shoes. One must include strengthening foot, ankle, and calf muscles, along with a change of form in the transition.
•    As a Runner’s World reader commented; “The proper way to set these experiments up would be to use NON-RUNNERS and have half run in conventional shoes, and the other in Vibrams and see how many develop injury. That way both groups are truly starting from zero, and neither group has an advantage over the other. Second, are both groups being taught the proper form for each shoe? I highly doubt it.”
•    So get stronger and healthier, run in better form, walk all day in minimal shoes, and gradually adapt to flatter and more minimal footwear as your body adapts.

This essay originally appeared on Dr. Nick Campitelli’s always-informative running blog. Go here.

Also for fun this sent from my friend Steve in New Zealand….watch the interview!

Hi Mark

I just had the pleasure of completing the Tarawera Ultra in Rotorua this weekend passed. Would love to see you down here in NZ, I’m sure you love this event. In the meantime, this story will cheer your heart, Ruby Muir from NZ took out the women’s 100k and 7th overall in world class company in a pair of Vibram See-yas!


10 Responses to “Avoid Injury: Make Slow Transition to Barefoot-style Running Shoes”

  1. Ken Gosleigh says:

    Why do elite runners run less than 10% of weekly volume in minimalist type shoes yet you are advocating recreational runners run the majority of their weekly volume in these types shoes (yes I know with the proper transition from traditional shoes)? I have communicating with a number of elite runners to confirm this, also the African elite runners train in traditional running shoes. Elite runners have the time to get daily physical therapy and do proper strength training. The recreational runner would have a full time job, family, etc. so guessing the supplementary training would be at a minimum. With strengthening of the feet, increase ankle flexibility and maybe a recreational runner should run 5% of weekly volume in minimalist shoes or barefoot.

    • Ryan says:

      Elite runners have some of the highest injury rates as well as some of the most severe injuries. The injury problem is so bad among elite runners that many can barely run at all by the time they hit 40-45 years old.

      I think the question is why would anyone advise a recreational runner follow what elite runners do when the are one of the most severely injured groups of athletes?

      This whole argument of “do what the elites do” is completely baseless and irresponsible.

    • MarkC says:


      as the comments are coming in I would attest the the elites crack more and worse than the rest….and the strong survive. look at Meb and Ritz. They have retooled everything. Meb is the new stardard of longevity. He spends hours now on core and form…and guess what he is wearing? minimal. Ritz also retooling all of his form and strength. not sure his preferred shoe but it is not about the shoe. Hall? He is out for the near future. These athletes put extreme loads on their bodies to WIN…this is NOT healthy for most. The body will adapt as long as the load applied are not greater than the capacity to adapt (Blaise Dubois).

      Most would place me in the age group elite category. Have not missed a day of injury since 2000 when my feet were operated and i went back to school on healthy running. I run well beneath my capacity and stay healthy. Running needs to be play and relaxing for sustainablity. For true elites it is a job and stress. That is not the case for the rest of us.

      So in summary just try minimalism smartly and progressively. See Dr. Mark’s Running School on http://www.tworiverstreads.com


  2. J Allen says:

    To answer your question, it’s all about longevity and efficiency and really learning how to run pain free. There is a big difference between elite runners and recreational runners. Recreational runners are not trying to break world records, they are running for the sake of running. My number one goal as a recreational runner is to run pain free and to be able to run pain free for many years to come. Between 1970s and early 2000s it was “normal” to hear runners complain about shin splints, plantar fasciitis, runners knee, Achilles Tendinitis, Hamstring Issues, Iliotibial Band Syndrome, and stress fractures, to name a few injuries. And to top it off, runners who didn’t complain about pain for the first 20 years of their running career, are having to quit in their 40’s and 50’s because their knees hurt too bad. Not all injuries are instant. The Shoe Industry would have us believe we need their shoes and their technology to keep our selves free from injury. This is FAR from the truth. Our feet our the million dollar technology that shoes are trying to recreate. Name an elite runner that has never or very seldomly complains about running injuries. I like Ryan Hall, but guess what, he gets shin splints and so forth. Barefoot/Minimal running at the end of the day is really about running pain free. Heel strike will lead to injury over time. So, if you want to run like the elites then go for it but be forewarned, you will also have to deal with the injuries that come along with it. If you want to run pain free then look into running barefoot/minimal.

  3. AxeS says:

    ” A 10-week study of less than 20 runners in each group with close to 20% drop out and poorly documented logs? This should say enough.”

    As one who regularly wears athletic apparel from Brigham Young University, I’m embarrassed that a study so clearly abounding in enormous margins of error would be published. To me it looks pretty clear that this study was student designed in one semester, and put into action the next semester with little thought of the actual ramifications or integrity of the study other than to finish within a semester and achieve a final grade. Not having the read the study, I will freely admit that I could be way off, but on surface that is what it looks like and it is a shame to have the University’s name muddied with such apparent amateurism.

    To continue with the discussion regarding the elites: Sometimes elites have the hardest time accepting what is good for them. What I mean by that is, a race car driver is not going to change a winning engine the day before his final championship, no matter how improved a completely restyled engine may look on paper. Similarly, most elites have grown up, both literally and in the sport, bathed in the mantra of cushion, stability, and high ‘technology’ shoes. Adding the stress of change on top of an already very stressful training regimen can mean risking elite status (which is usually a short time span compared to the time it took to get there, with no guarantee how long it will last). This is simply a risk most elites will not take. Most elite athletes (and coaches) are likely going to feel more comfortable using the engine that got them there rather than make a change at the climax of their careers, even when others have had success with the alleged change.

  4. I really like reading through a post that will make people think.
    Also, many thanks for allowing for me to comment!

  5. Doug says:

    If you want to learn to run barefoot, read this first: https://www.facebook.com/notes/dayton-barefoot-runner/i-want-to-run-with-better-form-where-do-i-start/455026104517519
    Post questions there if you have any.

  6. Pau Vela Maggi says:

    Hi, I’m an elite rower whose weight is 90kg and I’m a fan of barefoot running, but I have flat foot and i train three times a day, i wear orthotics aswell. What can i do to start to find the way to gain strenght anf flexibility in my foot? I have a lot of stress in my ankles and in my knees. Thanks for your help.

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