Comment on Barefoot Running Caroline Burge School
of Medicine, University of Queensland, Brisbane 4006, Australia. Email Sportscience 5(3),
sportsci.org/jour/0103/cb.htm, 2001 (1315 words) A
formal assessment of the quality of evidence indicates that much more
research is needed to confirm the effect of barefoot running on risk of
injury and on competitive performance.
Reprint pdf · Reprint doc KEYWORDS: Cochrane Collaboration, design,
injury, performance,
shoes |
|
In any
review, particularly with clinical implications, it is helpful if the authors
assess the quality of evidence on which the conclusions and recommendations
are based. The National Health and Medical Research Council recommends the
following hierarchical schema for quality of evidence:
This
hierarchy indicates the degree to which bias has been eliminated by research
design. Non-randomized and
observational studies are classified as Levels III and IV. Reviewers in the Cochrane Collaboration
usually include only randomized controlled trials (Levels I and II) in their
reviews of health-care studies (see the Cochrane
Reviewers' Handbook). Ioannidis et al. (2001, online)
counter this exclusive stance in a discussion of the relative merits of
interventional and observational studies. As
acknowledged in the present review, evidence that barefoot running reduces
risk of injury appears to be entirely observational. As such, it is premature
to recommend barefoot running for reducing the incidence of running-related
injuries. Evidence of a beneficial effect of barefoot running on performance
is better–possibly Level II–but as the author correctly identifies,
randomized controlled trials are needed with performance in real or simulated
competitions. It is
important that authors of reviews attempt to access all publications on a
given topic. As most articles published before 1966 are not computer indexed,
the author may have missed any pre-1966 studies that were not cited in more
recent publications. McLellan (2001, online) has written a relevant editorial on this issue.
Browsing old dusty journals packed away in the top floor of the library can
leave one amazed with what is already known, the good quality of the research
and the often elegant clear writing style. I wonder if these journals hide
lost secrets on barefoot running. The
author has presented the evidence in a manner that is reasonably typical of
reviews in the exercise science area.
The presentation of evidence could be improved by greater emphasis on
quantifying effects, preferably with meta-analytic techniques. The author has
provided only rough estimates of differences in running economy between
barefoot and shod running, and no quantification at all of effect sizes for
injury. Incidence rates of injury or
relative risks would give the reader a better idea of clinical relevance. A
review targeted at an audience of specialists and non-specialists would also
benefit from precise definition of terms such as impact and from plain-language explanations of some technical
terms. An
important issue in the review is the apparently questionable claims of shoe
manufacturers about the benefits of their products. The running and jogging
shoe industry is big business. In its advertising, claims have been made
about various improvements in design and materials. Some shoes, for example,
are designed to stabilize the foot and ankle by altering foot biomechanics,
whereas others have extra cushioning to reduce transmission of peak impact
force directly to foot and leg structures and possibly indirectly to other
structures, such as the lower spine and neck.
Any claims based on so-called corporate research need to be viewed
with certain skepticism, unless the study was published in a peer-reviewed
journal. Even then, corporate
sponsorship of a study may still result in substantial bias in outcomes
(Djulbegovic, 2000, online; Spurgeon, 2001, online). An issue
not addressed in the current review is the effect of individual differences
in anatomy on the mechanisms and risk of injury associated with wearing of
running shoes. Feet come in different
shapes and sizes, they support bodies of different mass and posture, and
their owners adopt different running styles. All this variability must be
accommodated by what seem to be relatively few shoe designs. Market prices
and regional availability further limit the runner's choice. A related issue
is the effect of age on a shoe's characteristics, and an athlete's perception
of shoe performance that is sub-standard through wear and tear. We apparently
do not know whether runners increase their risk of injury by wearing
inappropriate and/or worn-out shoes. Also not
addressed in this review is the issue of the role of shoes in the etiology of
stress fractures, a common injury in distance runners. The consequences of a
stress fracture, particularly those in the feet, are distressing. Tarsal
navicular stress fractures may remain undiagnosed for months and are
notorious for poor healing. If the fracture is managed non-surgically
(non-weight-bearing cast for 6 to 8 weeks), return to sport can take up to
six months. Painful fracture non-union requires internal fixation (Bojanic
and Pecina, 1997; Khan et al., 1994; Weinfeld et al., 1994). Metatarsal
stress fractures are also common in runners (Weinfeld et al., 1994). Not
wearing shoes may also accelerate development of other injuries in vulnerable
runners. Some of the common and most difficult injuries of the foot to
diagnose and treat, particularly if the injury becomes chronic, are presented
below. Inflammation
of the sesamoid complex of the first metatarsophalangeal joint is relatively
common in runners, as is inflammation of the peritendinous structures around
the sesamoid complex. A single event (a fall or direct blow on the sole of
the foot) can also trigger this type of injury (Potter et al., 1992).
Diagnostically, it is important to rule out avascular necrosis, a fractured
sesamoid, flexor hallucis longus tendinitis, capsulitis and synovitis of the
second metatarsophalangeal joint. A majority
of patients presenting with plantar heel pain have a mechanical etiology,
which may also be accelerated by not wearing shoes. Most of these patients
are overweight, and they hyperpronate and have intrinsic instability and/or
fat-pad atrophy. From an etiology standpoint, seropositive and seronegative
spondyloarthropathies and crystal deposition arthropathies need to be
excluded (Graham, 1983; Lapidus et al., 1965). Conservative treatment usually
involves wearing more supportive shoes and minimizing barefoot walking. Fat
pad syndrome (bruising of the fat pad from landing on a stone, for example)
may mimic plantar fasciitis and take weeks to heal. References Bojanic I, Pecina MM (1997). Conservative
treatment of stress fractures of the tarsal navicular in athletes. Revue de
Chirurgie Orthopedique et Reparatrice de l'Appareil Moteur 83, 133-138 Djulbegovic
B, Lacevic M, Cantor A, Fields KK, Bennett CL, Adams JR, Kuderer NM (2000).
The uncertainty principle and industry-sponsored research. Lancet 356,
635-638 Graham CE
(1983). Painful heel syndrome: rationale of diagnosis and treatment. Foot and
Ankle 3, 261-267 Ioannidis JP, Haidich AB, Lau J
(2001). Any casualties in the clash of randomised and observational evidence?
BMJ–British Medical Journal 322, 879–880 Khan KM,
Brukner PD, Kearney C, Fuller PJ, Bradshaw CJ, Kiss ZS (1994). Tarsal
navicular stress fracture in athletes. Sports Medicine 17 65-76 Lapidus
PW, Guidotti FP (1965). Painful heel: report of 323 patients with 364 painful
heels. Clinical Orthopaedics and Related Research 39, 178 McLellan
F (2001). 1966 and all that–when is a literature search done? Lancet 358, 646 Potter
HG, Pavlov H, Abrahams TG (1992). The hallux sesamoids revisited. Skeletal
Radiology 21, 437-444 Spurgeon
D (2001). News: report clears researcher who broke drug company agreement.
BMJ–British Medical Journal 323, 1085 Weinfeld
SB, Haddad SL, Myerson MS (1997). Metatarsal stress fractures. Clinics in
Sports Medicine 16, 319-338 Published Jan 2002 |