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Point-Counterpoint: Should We Recommend Motion Control Running Shoes?
Yes.
Citing recent research, this author notes motion control shoes can offer various benefits to runners in terms of preventing overuse injuries.
By Douglas Richie, DPM, FACFAS
Given the choice of making a recommendation for one specific category of running shoe for the general population, the podiatric physician should opt for motion control shoes with a high level of confidence. Forgetting performance, comfort, running economy and other factors, the podiatric physician should be primarily focused on recommending footwear for injury prevention. With this in mind, motion control running shoes are the best choice for the general population of runners.
However, before making such a sweeping recommendation, a few clarifications and warnings are in order. The definition of a “motion control” running shoe is somewhat obscure. Currently, running shoes are categorized by an ascending order of “stability” starting with “minimalist” and progressing through “neutral,” “stability” and “motion control” categories.1,2 Recently, we have seen the emergence of a new category of “maximalist” running shoes, a variation of neutral shoes with expanded thickness and cushioning in the midsoles.3
In terms of which shoes are best suited to foot types, Ryan and colleagues state: “Such a hierarchy presupposes that high arched supinating feet are better served in cushioned shoes, markedly over-pronating planus foot types should be fit with motion control shoes and foot types in between set to use either neutral or stability shoes as appropriate.”1 Further scrutiny of scientific research reveals that this supposition is without foundation.
Although consensus of opinion may be lacking, a “motion control” running shoe differs from a “neutral” shoe in having the following features: a heel drop of over 10 mm, a lateral heel or sole flare, a thermoplastic midfoot shank, and a dual-density midsole.4 In addition, motion control running shoes have firmer or “harder” midsoles than neutral shoes.5 It is interesting to learn if any of these shoe characteristics provide any benefit to the runner or to a specific foot type of the runner.
What Benefits Have Researchers Measured With Motion Control Shoes?
A study revealed that transverse plane tibial rotation was significantly reduced during running with motion control shoes in comparison to neutral shoes.6 Researchers validated the finding regardless of foot type or the degree of pronation shown by the runners. This reduction in tibial rotation has been linked to a reduced risk of running injury.7
Another study showed that in comparison to neutral shoes, runners wearing motion control running shoes have better activation of the quadriceps muscles, specifically the vastus medialis obliquus, which may reduce symptoms of patellofemoral pain syndrome.8
Finally, motion control shoes, in comparison to neutral shoes, may facilitate a more stable activation of and higher resistance to fatigue of the lower leg muscles during running, particularly in runners with pronated feet. This finding again suggests that motion control shoes might reduce overuse injuries in runners with pronated foot types.9
What About Heel Drop And The Risk Of Injury?
One key feature of running shoes that has drawn considerable controversy is the stack height of the heel and/or the relationship in height of the heel and forefoot portion of the shoe (i.e. the heel drop measurement).
Advocates of minimalist footwear have warned about posturing the foot in “equinus” with the elevated stack height present in stability and motion control shoes.10,11 This warning has been posted by fellow Podiatry Today blogger Nicholas Campitelli, DPM, FACFAS: “Today, traditional running shoes have an average drop of 12 mm with the heel being 24 mm and the forefoot being 12 mm. This design encourages an unnatural gait, resulting in the heel hitting the ground first and followed by a rapid ‘slapping’ of the forefoot.”12
Contrary to all these unfounded fears, heel drop in running shoes is not a predictive factor for the risk of injury. In a landmark study, Malisoux and coworkers demonstrated that there is no correlation between heel drop of running shoes and injury risk in a Level I prospective study of 553 runners.13 In fact, there was actually a higher injury risk experienced by regular runners wearing low-drop running shoes.
Are Motion Control Shoes Too ‘Hard’?
Theisen and coworkers found no relationship between midsole hardness and injury risk in recreational runners.5 This confounding conclusion from many scientific studies was echoed by Nigg, who observes: “The only two studies that addressed cushioning as an injury prevention strategy did not show a significant decrease of the injury frequency when changing the midsole
hardness.”14
Despite misconceptions about firmer or harder midsoles, motion control running shoes would not be expected to increase the risk of injury.
The question remains: Do “harder” running shoes actually prevent injury in certain runners?
Can Motion Control Shoes Prevent Injury?
A study by Malisoux and coworkers provided the best insight into the role of injury prevention and motion control footwear.4 This Level I prospective trial studied 372 recreational runners and documented injuries sustained from running during a six-month period. The study participants were randomly assigned either motion control running shoes, which contained a dual-density midsole and medial arch reinforcement, or standard running shoes, which did not contain those features. The results of the study are as follows:
- Participants who wore motion control shoes had a lower risk of running injury in comparison to participants who wore neutral shoes.
- When looking specifically at foot type, only runners with pronated feet demonstrated a reduced injury rate in motion control shoes.
- Runners with neutral and supinated foot types did not have higher injury rates in motion control shoes in comparison to neutral shoes.
- Overall, regardless of shoe type, runners with pronated feet had a higher injury risk.
- These runners with pronated feet had a higher rate of injury when wearing standard running shoes in comparison to motion control running shoes.
What is surprising to learn from this study is the suggestion that runners with supinated feet are not at higher risk of injury if they wear motion control shoes. All of this refutes the claim made by advocates of minimalist footwear that so-called “over-controlling” running shoes are detrimental to certain foot types.
Will Motion Control Shoes ‘Over-Control’ The Foot?
The notion of “motion control” might still pose a warning as certain foot types might respond differently to certain footwear design characteristics. Studies of certain motion control features of running shoes have demonstrated significant effects on rearfoot motion.15-21 In a systematic review of these studies, Cheung and colleagues found that motion control features in running shoes will reduce pronation by an average of 2.5 degrees, which is statistically significant but might not be clinically significant.22 In all these studies, the authors found that the dual density midsole feature was more effective for pronation control than midsole wedging or flare of the outsole of the running shoe.
In my own experience, the dual density midsole feature of motion control shoes can pose a detriment to certain patients who have lateral ankle instability or lateral hindfoot and ankle pathologies. The softer foam material found in the lateral aspect of the dual density midsole can break down and compress faster than the firmer medial midsole. This can lead to a gradual varus wedging in the rearfoot section of the motion control shoe, particularly in those individuals with large body mass or significant rearfoot varus deformity.
A study by Malisoux and coworkers of motion control shoes may not have detected this breakdown of the dual density midsoles because the duration of use of the shoes was only six months.4 This may suggest that you should caution runners in motion control shoes to look for varus compression or breakdown of the midsole after six months of use.
Notwithstanding, motion control running shoes have firmer midsoles, both medial and lateral, than most neutral running shoes. In my experience, heavier runners, regardless of foot type, still perform better in motion control shoes than neutral shoes. However, the shoes need to be replaced when they break down laterally, which will occur in heavy individuals and those with varus hindfoot deformity.
What Is The Bottom Line With Motion Control Running Shoes?
Across the board in research, injury rates were lower for all foot types with motion control running shoes in the study by Malisoux and colleagues although only the pronated foot type achieved statistical significance.4 For those patients with neutral and supinated foot types, the design or construction of a running shoe does not appear to affect injury rate. Thus, there is no reason to condemn motion control running shoes based upon current research on incidence of injury.
However, more studies are needed that can demonstrate the benefits or detriment of certain styles of running shoes relative to injury incidence. In particular, we do not know what category of running shoe will prevent injury in supinated foot types. For now, we will still have to rely on intuitive thinking when making shoe recommendations to our patients with neutral and supinated foot morphology. If you do not know the foot type of the patient, the choice of a motion control running shoe is a safe recommendation.
Dr. Richie is an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif. He is a Fellow and Past President of the American Academy of Podiatric Sports Medicine. Dr. Richie is a Fellow of the American College of Foot and Ankle Surgeons. He is in private practice in Seal Beach, Calif.
References
1. Ryan MB, Valiant GA, McDonald K, Taunton JE. The effect of three different levels of footwear stability on pain outcomes in women runners: a randomised control trial. Br J Sports Med. 2011;45(9):715-721.
2. Sinclair J. Effects of barefoot and barefoot inspired footwear on knee and ankle loading during running. Clin Biomech (Bristol, Avon). 2014;29(4):395–399.
3. Sinclair J, Richards J, Selfe J, Fau-Goodwin J, Shore H. The influence of minimalist and maximalist footwear on patellofemoral kinetics during running. J Appl Biomech. 2016; 32(4):359-364.
4. Malisoux L, Chambon N, Delattre N, Gueguen N, Urhausen A, Theisen D. Injury risk in runners using standard or motion control shoes: a randomised controlled trial with participant and assessor blinding. Br J Sports Med. 2016;50(8):481-487.
5. Theisen D, Malisoux L, Genin J, et al. Influence of midsole hardness of standard cushioned shoes on running-related injury risk. Br J Sports Med. 2014;48(5):371–6.
6. Rose A, Birch I, Kuisma R. Effect of motion control running shoes compared with neutral shoes on tibial rotation during running. Physiotherapy. 2011; 97(3):250–255.
7. Eslami M, Begon M, Farahpour N, Allard P. Forefoot-rearfoot coupling patterns and tibial internal rotation during stance phase of barefoot versus shod running. Clin Biomech. 2007;22(1):74–80
8. Cheung RTH, Ng GY. Motion control shoe affects temporal activity of quadriceps in runners. Br J Sports Med. 2009; 43(12):943–7.
9. Cheung RTH, Ng GY. Motion control mshoe delays fatigue of shank muscles in runners with overpronating feet. Am J Sports Med. 2010; 38(3):486-491.
10. Goss DL, Gross MT. Relationships among self-reported shoe type, footstrike pattern, and injury incidence. US Army Med Dep J. 2012; 25-30.
11. Chambon N, Delattre N, Gueguen N, Berton E, Rao G. Shoe drop has opposite influence on running pattern when running overground or on a treadmill. Eur J Appl Physiol. 2015;115(5):911-918.
12. Campitelli NA. Do running shoes still need heels? Podiatry Today DPM Blog. Available at https://www.podiatrytoday.com/blogged/do-running-shoes-still-need-heels . Published Jan. 19, 2012.
13. Malisoux L, Chambon N, Urhausen A, Theisen D. Influence of the heel-to-toe drop
of standard cushioned running shoes on injury risk in leisure-time runners. A randomized controlled trial with 6-month follow-up. Am J Sports Med. 2016; 44(11):2933-2940.
14. Nigg BM, Baltich J, Hoerzer S, et al. Running shoes and running injuries: mythbusting and a proposal for two new paradigms: ‘preferred movement path’ and ‘comfort filter’. Br J Sports Med. 2015;49(20):1290–1294.
15. Cheung RTH, Ng GYF. Efficacy of motion control footwears for reducing excessive rearfoot motion in fatigued runners. Phys Ther Sports. 2007;8:75–81.
16. Yamashita MH. Evaluation and selection of shoe wear and orthoses for the runner. Phys Med Rehabil Clin N Am. 2005;16(3):801–29.
17. Butler RJ, Davis IS, Hamill J. Interaction of arch type and footwear on running mechanics. Am J Sports Med. 2006;34(12):1998–2005.
18. Clarke TE, Frederick EC, Hamill CL. The effects of shoe design parameters on rearfoot control in running. Med Sci Sports Exerc. 1983;15(5):376–81.
19. Hamill J, Freedson PS, Boda W, et al. Effects of shoe type on cardiorespiratory responses and rearfoot motion during treadmill running. Med Sci Sports Exerc. 1988;20(5):515–21.
20. Kersting UG, Brüggemann GP. Midsole material-related force control during heel-toe running. Res Sports Med. 2006;14(1):1–17.
21. Milani TL, Schnabel G, Hennig EM. Rearfoot motion and pressure distribution patterns during running in shoes with varus and valgus wedges. J Appl Biomech. 1995;11:177–87.
22. Cheung RT, Chung RC, Ng GY. Efficacies of different external controls for excessive foot pronation: a meta-analysis. Br J Sports Med. 2011;45(9):743–51.
No.
This author says there is a lack of clarity in the literature about the role of excessive pronation with running injuries and maintains that motion control shoes disrupt the normal motions of the foot while running.
By Nicholas A. Campitelli, DPM, FACFAS
Without a doubt, choosing a running shoe is one of the most common strategies that runners use to address an injury or prevent one. In my practice, I routinely hear patients say, in the face of injury, “but I buy good shoes.”
What exactly is a “good” shoe? Should we focus on cost? Do we need to buy the latest model that each shoe company introduces each year to ensure our foot is in the best shoe available to prevent the likelihood of injury? Is there any validity to the idea that a motion control shoe will prevent injury or improve one’s running in any way, shape or form? My belief is that we cannot solve running injures by shoe gear alone. In fact, shoegear, in my opinion, has very little to do with resolving an injury when it comes to running.
It has been well established that the incidence of running injuries in those wearing traditional running shoes can reach as high as 79.3 percent.1 What then is causing such a high rate of injury in this day and age when we have at our disposal an unlimited selection of shoes from a billion-dollar industry?2 My belief is that running shoes do very little for our feet in terms of controlling motion. More importantly, I believe running shoes do little to help our biomechanics when it comes to running.
Addressing Misconceptions On Overpronation And Injuries
To begin the discussion, we live in a society where some people incorrectly believe that they have a flat foot or that they overpronate.3 Researchers often implicate excessive pronation as a contributing factor to overuse injuries.4 While two prospective studies have linked foot mechanics to overuse injuries, Ferber and colleagues, in their literature review, note that the relationship between rearfoot position and running injury is not clear in regard to excessive pronation being a leading factor.4-6
Another inherent flaw that exists when it comes to studying runners is controlling all of the variables. The trend for studying runners had initially evolved from observing foot type to watching someone run and determining the amount of pronation observed during various phases of gait. If the clinician observed increased or excessive pronation, the goal was to control it. More recently, researchers have shifted the focus to observing foot strike patterns in runners.7–9 This shift to foot striking, in my opinion, may negate the findings of many of these early studies or anecdotal evidence based on excessive pronation if the studies did not control or mention the variable of foot strike.
I believe if you are evaluating runners and treating their injury based on increased pronation and they are heel striking, you may be missing the boat on the true cause of the injury. Recent studies have demonstrated a reduction in injury for those who are forefoot or midfoot strikers as opposed to heel strikers.8–10 In essence, one would have to redefine the gait cycle with respect to pronation when a runner is forefoot or midfoot striking. To my knowledge, there is no existing study that describes the proper “running gait cycle.”
Most clinicians follow the classic heel strike, midstance and propulsive phases of gait, and then determine how much pronation is occurring around those phases. The problem I have with this is that when someone strikes at the midfoot or forefoot, the phases of gait occur in opposite directions and the pronation is occurring between the initial contact period of forefoot or midfoot striking, and ending when the heel hits the ground. This completely redefines what most clinicians have typically used to base their thoughts on whether the runner is excessively pronating.
Other Considerations With Injury Prevention In Runners
We also know that when selecting shoegear, there is no evidence-based study for shoe selection based on foot type.10 There is too much focus on foot type as being a cause of injury or pathology.
While it may be hard to conceptualize, we have to abandon the distorted belief that flat feet are so prevalent in our society along with the idea that these supposed flat feet are the cause of injury. While there is an inadvertent belief that arch height is a factor in defining a pathologic foot, arch height, in my opinion, is nothing more than a variant of foot types, which has little if any bearing on injury predisposition when it comes to running. Severe cases of flat feet that may lead to posterior tibial tendon dysfunction (PTTD) exist but rarely occur among runners in my experience. Most people with true PTTD can barely function when it comes to performing daily activities in their job and would not even consider running as a possibility.
Many of these patients with PTTD in my practice are already wearing some form of a rigid or motion control shoe, and are not seeing relief. They then wear a controlled ankle motion (CAM) walker as the standard of care in first-line therapy, which can reduce motion and splint the foot and ankle. The CAM walker and custom ankle-foot orthotics (AFOs) that control ankle and subtalar joint range of motion are first-line therapies to treat true pathologic flatfoot.11 One would never think of running in one of these devices. This aforementioned scenario is the foundation upon which I base my approach when it comes to treating running injuries.
When the musculature in your feet become too fatigued and your foot starts losing control, then it is time to stop running and focus on strengthening the foot, and improving form. An improper training pattern is one of the number one reasons I see runners get injured. They do too much and also run too fast without building a proper endurance base that is crucial to running. With the emergence of studies that have looked at the effects of functioning in minimalist shoes and barefoot, we know the foot becomes stronger under these conditions.12-14
Sometimes we look too hard to find answers that already exist. Consider soccer players, for example. They run on average 7 miles per game and sometimes will reach up to 9.5 miles in a single game.15 Studies have looked at injury rates in soccer players and discovered that overuse is the leading cause of lower limb injuries.16 Even further, studies have advocated adapting to higher chronic loads of running and better intermittent aerobic fitness to reduce lower limb injury associated with running.17 The point is that soccer players more than likely log more miles running than the average recreational runners, who are seeing the high injury rates. In my experience, soccer players are focusing more on training patterns to address injures as opposed to orthotics or shoes.
Why The Author Does Not Recommend Motion Control Shoes
I do not recommend motion control shoes in my practice as I feel there is not enough evidence to do so. While one might argue there is not sufficient evidence for use of minimalist shoes, my belief is a minimalist shoe will not disrupt natural running mechanics and facilitates shock absorption.
I feel motion control shoes will disrupt the natural movement that should be occurring in the foot. The foot has become the only part of our body that is splinted with an external device to stop normal motion from occurring. One would never place a sling or brace on a pitcher, and then ask him or her to throw a baseball as this disrupts the normal shoulder mechanics. I see motion control shoes interrupting the normal mechanics of the foot and ankle in this same manner.
So are motion control shoes the fix for running injuries? Absolutely not. The foot and rest of the body need to act in a way that is natural with nothing restricting normal motion. If you have to rely on a shoe to run, you shouldn’t be running.
Dr. Campitelli is an Adjunct Professor at the Kent State University College of Podiatric Medicine. He is in private practice at North East Ohio Medical Associates.
References
1. Van Gent RN, Siem D, van Middelkoop M, van Os AG, Bierma-Zeinstra SM, Koes BW. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. Br J Sports Med. 2007;41(8):469.
2. Grand View Research. Athletic footwear market analysis, market size, application analysis, regional outlook, competitive strategies and forecasts, 2016 to 2024. Available at https://www.grandviewresearch.com/industry-analysis/athletic-footwear-market .
3. Hohmann E, Reaburn P, Imhoff A. Runner’s knowledge of their foot type: do they really know? Foot (Edinb). 2012;22(3):205-10.
4. Ferber R, Hreljac A, Kendall KD. Suspected mechanisms in the cause of overuse running injuries: a clinical review. Sports Health. 2009;1(3):242-246.
5. Willems TM, De Clercq D, Delbaere K, Vanderstraeten G, De Cock A, Witvrouw E. A prospective study of gait related risk factors for exercise-related lower leg pain. Gait Posture. 2006; 23(1):91-8.
6. Willems TM, Witvrouw E, De Cock A, De Clercq D. Gait-related risk factors for exercise-related lower-leg pain during shod running. Med Sci Sports Exerc. 2007; 39(2):330-9.
7. Lorenz DS, Pontillo M. Is there evidence to support a forefoot strike pattern in barefoot runners? A review. Sports Health. 2012;4(6):480-4.
8. Daoud AL, Geissler GJ, Wang F, Saretsky J, Daoud YA, Lieberman DE. Foot strike and injury rates in endurance runners: a retrospective study. Med Sci Sports Exerc. 2012;44(7):1325-34.
9. Goss DL, Gross MT. A review of mechanics and injury trends among various running styles. US Army Med Dep J. 2012 July; 62-71.
10. Richards CE, Magin PJ, Callister R. Is your prescription of distance running shoes evidence-based? Br J Sports Med. 2009;43(3):159-62.
11. Ling SK, Lui TH. Posterior tibial tendon dysfunction: an overview. Open Orthop J. 2017; 11:714-723.
12. Campitelli NA, Spencer SA, Bernhard K, Heard K, Kidon A. Effect of Vibram FiveFingers minimalist shoes on the abductor hallucis muscle. J Am Podiatr Med Assoc. 2016;106(5):344-351.
13. Johnson AW, Myrer JW, Mitchell UH, Hunter I, Ridge ST. The effects of a transition to minimalist shoe running on intrinsic foot muscle size. Int J Sports Med. 2016;37(2):154-8.
14. Chen TL, Sze LK, Davis IS, Cheung RT. Effects of training in minimalist shoes on the intrinsic and extrinsic foot muscle volume. Clin Biomech (Bristol, Avon). 2016;36:8-13.
15. STATS SportVU football player tracking. Available at https://www.stats.com/sportvu-football/ . Accessed January 19, 2018.
16. Bacon CS, Mauger AR. Prediction of overuse injuries in professional U18-U21 footballers using metrics of training distance and intensity. J Strength Cond Res. 2017;31(11):3067-3076.
17. Malone S, Owen A, Mendes B, Hughes B, Collins K, Gabbett TJ. High-speed running and sprinting as an injury risk factor in soccer: Can well-developed physical qualities reduce the risk? J Sci Med Sport. 2017; epub May 25.
For further reading, see the DPM Blogs “When Athletes Falsely Believe That Snug Shoes Are Optimal” at https://tinyurl.com/y9zhrhlq and “What A Recent Study Revealed About Runners And Motion Control Shoes” at https://tinyurl.com/y785toge .
