Minimalist Footwear - Pedorthic Association of Canada

Minimalist
Footwear
WINTER 2013
03
President’s Message
04
Examining a Biomechanical Basis for
Injury Prevention with Minimalist
Running Footwear
06
Article Review: Examining the
Degree of Pain Reduction Using a
Multielement Exercise Model with a
Conventional Training Shoe versus an
Ultraflexible Training Shoe for
Treating Plantar Fasciitis
10
Breaking Down Minimalist Footwear
Features
10
Metatarsal Stress Fracture Relating
to Minimalist Footwear – Case Study
11
Use of Custom Orthotics with
Minimalist Footwear
14
The Retail Side of Minimal Shoes
16
Member Profiles
A Periodical of the Pedorthic Association of Canada
A Periodical of the Pedorthic Association of Canada
Winter 2013
President’s Message
ryan robinson, C. Ped Tech (C), C. Ped (C)
Happy New Year everyone! Another year has come and gone,
and a new one is just beginning. Hopefully all of you had a
chance to spend some much needed time with family and
friends, and you are now revitalized, refreshed and ready
to take on the new year - although perhaps some of us are
filing for bankruptcy due to all the gift buying (how can a kid’s
scooter cost $200 anyhow?). Some of us might also be exhausted from entertaining the
constant flow of family and friends, and 5 pounds heavier from all the delicious food we
consumed. I need another vacation!
The holidays are a time to reflect on the past year, and everything it held. For me, 2012
was definitely a year to remember. I have a lot to be thankful for. I have a fantastic
wife, 2 great kids, a successful business that I enjoy, and I am the current President of a
wonderful profession.
Publisher Information
Pedorthics Quarterly
A Periodical of the Pedorthic Association of Canada
Pedorthics Quarterly is published by:
Pedorthic Association of Canada
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I consider myself very lucky to be involved with the Pedorthic profession, and to
represent you as your President. The holiday time has a wonderful way of putting
everything in perspective, and helping to illuminate what is really important. For me, it
is the relationships that I have with others that are most important. From our immediate
and extended family, to our friends and many colleagues, these relationships help
define who we are.
Communications Committee
My position within the Pedorthic Association has enabled me to meet new colleagues
from across the country, and around the world for that matter. The friendships that I
have gained from my time on the board are ones that I know will last a lifetime. I look
forward to every teleconference and in-person meeting, as I have come to think of these
people as friends.
Committee Members
In addition to reflecting on the previous year, I also had some time over this holiday
season to consider my goal setting for 2013. Like many of you, I try every year to have a
game plan, a plan of attack, and a list of things that I would like to accomplish by year’s
end. I might not be able to check off all the items on this laundry list, but I’m darn sure
going to try.
If you haven’t already done so, take some time to set some goals for yourself this year.
They might be personal. Perhaps you want to run a marathon, spend more time with
family, or just take better care of yourself. These goals might also be professional. You
might want to advance in your career as a Pedorthist, learn a new skill, or maybe even
open your own clinic. One of the beauties of a career in Pedorthics is that it offers
so much potential for a motivated person to grow within their career, and in their
profession. Take advantage of the opportunities that are given to you!
Chair
Nancy Kelly, C. Ped Tech (C), C. Ped (C)
Vice Chair
Amy Guest, C. Ped (C)
Alex Whyte, C. Ped (C)
Crystallee Ripak, C. Ped (C)
Grace Boutilier, C. Ped Tech (C), C. Ped (C)
Jim Pattison, C. Ped (C)
Michael Ryan, C. Ped (C), PHD
Tavish Lahay-Decker, C. Ped (C)
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are the property of the Pedorthic Association of
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is permitted only with the prior written consent
of the Pedorthic Association of Canada. Address
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used only for the purpose of information.
Whatever YOUR goals are, I hope you reach them.
Help Us Be Green!
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We would appreciate your feedback on the PQ and its articles. Your ideas and thoughts are
important to us. Let us know what you think.
E-mail your letter (referencing the article title and PQ edition) to: info@pedorthic.ca. Please
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If you are interested in contributing articles for the PQ, contact info@pedorthic.ca.
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contact the PAC office at info@pedorthic.ca.
To those of you who are already receiving the
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green!
Did you know you can read past issues of the
Pedorthic Association of Canada quarterly
publication online? Go to www.pedorthic.ca
and log in to your member record.
3
Examining a Biomechanical
Basis for Injury Prevention with
Minimalist Running Footwear
Michael Ryan, PhD, C. Ped (C)
There are claims among various manufacturers that wearing
minimalist shoes can both improve running performance,
and reduce the probability of sustaining a running injury. The
performance claim is relatively easy to substantiate, as many
models in the minimalist category weigh considerably less than
conventional running shoes; a reduction of 100g from running
footwear has been associated with a 1% improvement in running
performance[1]. The table outlining differences between various
models of minimalist shoes, presented elsewhere in this quarterly,
illustrates there can be as large as an 8-ounce (226.8g) discrepancy
in the weight of a minimalist shoe from a conventional neutralsupportive model. In addition, elastic energy may be better utilized
when running barefoot. Early comparisons between barefoot and
shod running reported greater pre-activation of ankle plantarflexors
(resulting in higher active pre-stretch levels), as well as a reduction
in ground contact time when running barefoot. This suggests better
storage and restitution of elastic energy from posterior lower leg
soft-tissue (specifically the Achilles tendon). The greater efficiency
of barefoot running over shod was demonstrated by Divert et al.[2]
in 2008. It was speculated to primarily be a function of an increased
vertical component of the ground reaction force when running
barefoot, coupled with the shift from a rearfoot to midfoot strike
pattern.
From a clinical standpoint, the implications of minimalist footwear
are complex yet poorly understood. To date, there is no published
evidence that use of a minimalist shoe can affect the epidemiology
of running injuries. The information that is available stems from
studies that have collected biomechanical data on runners using
a standard running shoe, one or two minimalist footwear models,
and/or barefoot that is cataloged, analyzed and interpreted for
theoretical injury prevention mechanisms. These theoretical
mechanisms are then cross-referenced with known biomechanical
risk-factors for a given set of running injuries, and the preventative
link for minimalist footwear is established. Unfortunately, there
are two flaws with this approach. First, evidence gathered through
this approach is circumstantial and merely demonstrates potential
associations between a collection of congruent variables; it does not
report causation. The absence of direct evidence of this preventative
effect reveals it is unknown whether such a link is true, and under
what circumstances this truth holds. The second flaw is the
unsystematic application of minimalism to this footwear category
(indeed, this is a flaw inherent in any footwear research but its
effects are acute in minimalist running shoes). One cannot consider
all minimalist shoes to be created equally, and these differences
could have substantial effects on the relative risk of sustaining
an injury. With this background in mind, and understanding the
injury preventative effect of minimalist footwear is not complete,
4
a summary of potential biomechanical effects of minimalist shoes
will follow.
It is through 3 primary mechanisms that minimalist footwear might
reduce the injury potential of a runner: the position of the foot at
initial contact, lower extremity posture changes throughout stance,
and increased strength of foot and lower leg soft tissue. One key
biomechanical difference between barefoot and shod running is
that the ankle is more plantarflexed while barefoot running at initial
ground contact, allowing the medial longitudinal arch of the foot
to initially attenuate the force of body weight[3, 4]. As a result, the
rate of initial loading and the magnitude of the initial impact peak
is lower in barefoot running than shod. In fact, in most barefoot
runners, there is a complete absence of an initial impact peak.
These mechanical aspects are clinically relevant, as Hreljac[5] has
postulated that impact forces are important as a causative factor
for running injuries. Also, Milner et al.[6] and Zifchock et al.[7] have
shown that impact loading characteristics of runners are associated
with the occurrence of tibial stress fractures.
The posture of the lower extremity during initial ground contact,
and throughout the stance phase of running, has the potential to
substantially alter how the joints of the lower extremity are exposed
to the stresses of impact and propulsion. Analysis of runners running
barefoot typically will flex their knees and hips less, evert their
ankles less, internally rotate their hips less, and run with a higher
cadence compared to running shod. Any one of these postural
changes might be protective against running injuries [2-4]. The
reason for this modified lower extremity posture during barefoot
running is hypothesized to be a function of the body’s preparation
for ground contact, by preferentially adopting a midfoot foot strike
pattern - coupled with increased pre-activation of the triceps surae
m. to increase the stiffness of the ankle during impact [8]. The lower
extremity thus becomes stiffer when resisting the impact from body
weight, which might result in reduced loading at the patellofemoral
joint of the knee and a lower overall excursion of the hips. Indeed,
previous authors have reported an association between increasing
step-rate (cadence), lower peak knee and hip flexion, and reduced
forces acting on the knee and hip - which may be protective against
common running injuries such as patellofemoral pain syndrome,
infrapatellar tendinopathy, and injuries related to insufficiencies
of hip stabilizers/external rotators such as gluteus medius m. and
piriformis m. [9, 10]. As ankle eversion is a large component of foot/
ankle pronation, the reduction in peak ankle eversion with barefoot
running may be protective against running injuries of the Achilles
tendon [11, 12], lower leg[13], and knee[14]. A question remains,
however, whether running barefoot or in minimalist shoes is a
necessary requirement for runners to adopt a stiffer, midfoot strike
pattern. Especially, it has been shown that such a running posture is
possible wearing conventional running shoes while simply increasing
step-rate [9]. It is hypothesized that runners might, when running
barefoot, instinctively modify their running form in the interest of
mitigating impact shock on plantar foot tissue during heel strike.
However, it is unknown to what extent a shoe’s stability or cushion
elements must be reduced in order to illicit such biomechanical
changes mentioned previously.
A Periodical of the Pedorthic Association of Canada
A third avenue that barefoot or minimalist running is alleged to reduce
injuries is through selective strengthening of plantar intrinsic foot
muscles and soft-tissue. Evidence for this is almost entirely anecdotal
- with majority of claims originating from individuals who have
successfully adopted minimalist running, or track and field coaches
who utilize systematic exposure to barefoot running as an adjunct
training tool [15]. Early research in the concept of barefoot running
suggested that increased exposure to barefoot activities, including
running, can result in anatomical changes to the medial longitudinal
arch and overall foot posture [16, 17]. The potential that the positive
adaptations from barefoot running can be translated into a minimalist
footwear design have been tested at the Cologne Sports Science
Institute, where they report significant improvements to foot strength,
muscle cross-sectional area, and agility [18].
The ability of either a minimalist shoe design, or barefoot running, to
prevent or treat running injuries directly remains wholly untested. It is
recommended that any runner interested in using a minimalist shoe,
or clinician looking to refer their use, do so only under the advice that
they be incorporated with a very conservative progression. While
formally untested, it is nevertheless intuitive that factors such as injury
history, weekly running mileage, running experience, and previous
footwear stability sub-category used will impact a runner’s tolerance
to minimalist footwear.
Winter 2013
13. Bennett, J., et al., Factors contributing to the
development of medial tibial stress syndrome in
high school runners. J Orthop Sports Phys Ther,
2001. 31(9): p. 504-10.
14. Barton, C., et al., Kinematic gait characteristics associated with patellofemoral
pain syndrome: a systematic review. Gait Posture, 2009. 30(4): p. 405-16.
15. Robillard, J., The Barefoot Running Book Second Edition: A Practical Guide to
the Art and Science of Barefoot and Minimalist Shoe Running, ed. D. Wierenga.
2010, Allendale: Barefoot Running University.
16. Robbins, S. and A. Hanna, Running-related injury prevention through barefoot
adaptations. Med Sci Sports Exerc, 1987. 19(2): p. 148-56.
17. Sachithanandam, V. and B. Joseph, The influence of footwear on the prevalence
of flat foot. A survey of 1846 skeletally mature persons. J Bone Joint Surg Br. , 1995.
77(2): p. 254-7.
18. Bruggemann, G., et al., Effect of increased mechanical stimuli on foot muscles
functional capacity., in ISB. 2005, American Society of Biomechanics: Cleveland.
p. 553
References
1. Catlin, M. and R. Dressendorfer, Effect of shoe weight on the energy cost of
running. Med Sci Sports Exerc, 1979. 11: p. 80.
2. Divert, C., et al., Barefoot-shod running differences: shoe or mass effect?
International Journal of Sports Medicine, 2008. 29(6): p. 512.
3. Squadrone, R. and C. Gallozzi, Biomechanical and physiological comparison of
barefoot and two shod conditions in experienced barefoot runners. J Sports Med
Phys Fitness, 2009. 49(1): p. 6-13.
4. De Wit, B., D. De Clercq, and P. Aerts, Biomechanical analysis of the stance
phase during barefoot and shod running. J Biomech, 2000. 33(3): p. 269-78.
5. Hreljac, A., Impact and overuse injuries in runners. Med Sci Sports Exerc, 2004.
36(5): p. 845-9.
6. Milner, C., et al., Biomechanical factors associated with tibial stress fracture in
female runners. Med Sci Sports Exerc, 2006. 38(2): p. 323-8.
7. Zifchock, R., I. Davis, and J. Hamill, Kinetic asymmetry in female runners with
and without retrospective tibial stress fractures. J Biomech, 2006. 38(15): p. 2792-7.
8. Divert, C., et al., Mechanical comparison of barefoot and shod running. Int J
Sports Med, 2005. 26(7): p. 593-8.
9. Heiderscheit, B.C., et al., Effects of step rate manipulation on joint mechanics
during running. Med Sci Sports Exerc, 2011. 43(2): p. 296-302.
10. Derrick, T.R., J. Hamill, and G.E. Caldwell, Energy absorption of impacts during
running at various stride lengths. Medicine and science in sports and exercise,
1998. 30(1): p. 128.
11. Ryan, M., et al., Kinematic analysis of runners with achilles mid-portion
tendinopathy. foot Ankle Int, 2009. 30(12): p. 1190-5.
12. Azevedo, L., et al., Biomechanical variables associated with Achilles
tendinopathy in runners. Br J Sports Med, 2009. 43(4): p. 288-92.
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5
Article Review:
Examining the Degree of Pain Reduction
Using a Multielement Exercise Model with
a Conventional Training Shoe versus an
Ultraflexible Training Shoe for Treating
Plantar Fasciitis.
Grace Boutilier, C. Ped Tech (C), C. Ped (C)
Ryan MB, Fraser S, MacDonald K, Taunton JE. (2009). The
Physician and Sports Medicine. 37(4):1-7.
Introduction
Plantar fasciitis is a common running-related injury, but its affects
appear to have far-reaching implications for individuals who
are required to stand for prolonged periods as part of their daily
employment. Treatment modalities such as foot orthoses, night
splints, corticosteroid injections and physical therapy, among others
have produced somewhat equivocal results1-5. Delving further
into possible treatment options, researchers from the University
of British Columbia recently performed a randomized controlled
pilot trial attempting to shed light on the novel application of the
ultraflexible training shoe (Nike Free), in combination with a 12-week
multielement exercise program to a cohort of 24 injured adults.
Inclusion
Participants were recruited from advertisements in local newspaper
media, and were diagnosed as having plantar fasciitis by an
experienced physical therapist. They were diagnosed if they tested
positive for tenderness to pressure at the origin of the plantar
fascia on the medial tubercle of the calcaneus, coupled with sharp
shooting inferior foot pain made worse with activity and/or on rising
in the morning. Subjects were excluded if they presented with any
comorbidities of the lower extremity, foot or ankle, had symptoms
for less than 6 months, or had a history of systemic inflammatory
disease, connective tissue disease or previous local trauma to the
legs or feet.
Protocol
Participants were randomly assigned to 1 of 2 groups: 1) a group
wearing an ultraflexible shoe, which was Nike Free 5.0 (FREE) or
2) a group in which subjects wore their own conventional running
shoes (CON). All shoes in the CON group were confirmed to be
classified as either a neutral-supportive, or stability running shoes
with similar sole and upper characteristics (thermoplastic midfoot
shank and heel counter, and reinforced cushioned material in the
heel midsole). A 12-week, four-times-a-week exercise treatment
regime was assigned to both groups, with exercises focusing
on static and dynamic stretching and balance improvements.
Participants performed all exercises with the exception of a tissue-
Custom made “house shoes” are now
available for a VERY low cost when
added to a custom shoe order.
6
A Periodical of the Pedorthic Association of Canada
specific plantar fascia stretch while wearing footwear. Adherence
to the program was affirmed on an ongoing basis, as each subject
submitted a weekly training log and received a phone call each
week to ensure clarity and execution of the exercise program. A
visual analogue scale was used to measure peak pain levels in the
24 hours prior to assessment, with these testing sessions occurring
at initial (baseline), midprogram and conclusion of the study. A
6-month follow up was also performed.
Results
Twenty-one subjects (9 FREE, 12 CON) completed the study.
Three subjects (all from the FREE group) dropped out, with two
experiencing an increase in foot pain. A main effect of time was found
for the physiotherapy regime, demonstrating a significant reduction
in plantar fasciitis pain in both groups. There were no differences in
adherence to the exercise regime between groups. The FREE group
had significantly greater overall symptom duration. There were no
significant differences in pain across footwear groups, but the study
did find a trend lower mean pain score in the FREE group at the 6and 12-week test points. There were no significant differences found
between groups for pain levels at 6-month follow-up.
Discussion
The authors report that the implications of this study for pain relief
in a population with longstanding (>6-month symptom duration)
plantar fasciitis are substantial, reinforced by the fact that half of the
participants indicated that they were required to stand for >7 hours
per day. They suggest that the increased sole flexibility of the Nike
Free 5.0 enable the foot to “better engage its windlass mechanism
during toe-off, resulting in great strain on the intrinsic soft tissue
structures from an increase in the mechanical work of the foot coupled with greater storage and release of elastic components.”
This increased loading in a controlled setting has been shown to
be successful in treating other chronic soft-tissue injuries such as
Achilles, infrapatellar, and elbow extensor tendons.
Limitations
The authors acknowledge some limitations to the study, including
the small sample size (a given when performing pilot work) and the
weight of losing three subjects. They further mention the future
usefulness of adjunctive diagnostic criteria beyond those used in
this study (sensitivity to palpation and self-report pain), advocating
the efficacy of including both structural and function indices (e.g.
Foot Function Index, kinematic, imaging, and electromyographic
data). The authors also acknowledge a possible intervention bias
in that only 1 of the 2 groups received new footwear. While both
groups showed a reduction in peak pain (30% CON, 63% FREE), the
introduction of novel footwear may have inflated FREE group’s VAS
responses.
Circumstances surrounding footwear condition and categorization
are insufficient and vague. The researchers fail to provide any
information pertaining to the existing footwear in the CON group,
specifically regarding age and condition. Both neutral and stability
running shoe styles were permitted in the CON, mostly likely as a
means to rule out any effect of footwear change over the course
of the study for this cohort. It is probable that the authors agree
that further separation of these two categories of footwear within
winter 2013
the CON group, which were here
lumped together, could present some
interesting discrepancies in subjective
pain responses. In fact, they have since done research looking at the
differences between footwear in the neutral and stability category.
The authors also note that 81% of participants had previously
attempted to treat their pain with orthoses intervention. However,
there is no indication as to whether participants continued using
orthoses up until the time of the study, and if so, whether either
test group were instructed to continue using their orthoses. Readers
might assume that those in the FREE condition did not use orthoses,
however this is not specifically stated and thus creates confusion in
interpreting findings.
While care was taken to perform fastidious statistical analysis, it
could be argued that a multi-intervention approach (footwear and
exercise program) may confound the results of the FREE group’s
perceptions of pain. That is, one intervention may have had a
greater effect than the other, there may have been a combined
effect, or conversely one intervention could have cancelled out a
more positive outcome of the other.
Finally, the authors concede that while a 6-month follow up is
valuable to discern the longevity of findings, they also suggest a
12 to 24-month follow up program would serve to more strongly
confirm the long term treatment outcomes. Readers might further
be interested in both groups’ subjective interpretations of the
footwear they used, and whether those in the FREE group continued
using the shoes post-study.
Conclusion
This study found statistically significant support for the application
of a 12-week multielement exercise regimen that incorporates
static and dynamic stretching, and balance exercises in the
treatment of chronic pain (>6 months ) associated with plantar
fasciitis. Additional trends may indicate a relationship between
decreased shoe structure and symptom reduction, though greater
sample size and more clearly defined CON categories are needed
to validate these claims. This is a valuable contribution to the field
of pedorthics, and merits future investigation that should include
additional disease-specific outcome measures (such as foot posture
indices, ultrasound, magnetic resonance imagining, etc).
References
1. Roos E, Engström M, Söderberg F. (2006). Foot orthoses for the treatment of
plantar fasciitis. Foot Ankle Int. 27(8): 606-611.
2. Landorf K., Keenan AM, Herbert RD. (2006). Effectiveness of foot orthoses to
treat plantar fasciitis: a randomized trial. Arch Intern Med. 166(12):1305-1310.
3. Hawker F, Burns J, Radford JA, Toit V. (2008). Custom foot orthoses for the
treatment of foot pain. Cochrane Database Syst Rev. 3: CD006801.
4. Crawford F, Atkins D, Young P, Edwards J. (1999). Steriod injections for the
treatment of plantar fasciitis: evidence of short term effectiveness. A randomised
controlled trial. Rheumatology. 38(10):974-977.
5. Greve JM, Grecco MV, Santos-Silva PR. (2009). Comparison of radial shockwaves
and conventional physiotherapy for treating plantar fasciitis. Clinics (San Paulo).
64(2): 97-103.
7
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Breaking Down Minimalist
Footwear Features
Tavish Lahay-Decker, HBSc(Kin), C. Ped (C)
With so many minimalist shoes on the market now, it’s easy to get
lost in a sea of information. By utilizing the chart provided below,
we can help our patients understand the features that make these
minimalist shoes unique – and, which features may be appropriate
for them.
Shoe Model
Rearfoot/Forefoot
Heel/Forefoot
Mass
Stack heights (mm) Differential (mm) (Men’s size 10)
Nike Free Run+ 2
26/20
6
8.8
Newton Distancia
25/23
2
9.7
Brooks Green Silence
23/14
9
6.8
Nike 3.0 V3
17/13
4
7.0
Zoot Sports UltraSpeed
17/7
10
6.7
New Balance Minimus
12/8
4
8.2
Saucony Hattori
12/12
0
4.2
4/4
0
6.0
33/21
12
12.2
Vibram 5-Fingers Bikila
Nike Pegasus+ 28
limitations in dorsiflexion will not tolerate transitioning into a 0mm
immediately. Additionally, ensuring the patient has the appropriate
strength, biomechanics and correct running technique are extremely
important things to consider. There are cases where someone can
transition into minimalist footwear quite quickly, however it is
common to move slowly from a 12mm to 0mm as follows: 12mm
drop
10mm
8mm
6mm
4mm
2mm
0mm. The
need for this should be evaluated on a case-to-case basis.
Finally, to most runners the mass of the shoe is important; the
heavier the footwear, the more energy required to lift the foot. Dr.
Jack Daniels researched the differences between weight of the
shoe and the aerobic demand on a runner. He found that adding
100 grams to a shoe increased, the aerobic demand of running by
1%. Additionally, the Nike Research Laboratory found that marathon
times could be decreased by 3 minutes by removing 4oz. from a
shoe . While making the lightest shoe possible seems like the way
to go, Dr. Daniels also noted that when the shoe is made too light by
removing more of the midsole, the energy expenditure increased as
the muscles have to work harder to compensate for the loss in shock
absorption. The mass of the shoe will change depending on the size
of the shoe, so it is important to note that these weights are based
on a men’s size 10.
While there are other variables that are involved in determining
whether minimalist footwear is appropriate for your client, ideally
this guide should be able to help differentiate which type of footwear
might be a good starting point.
Special thanks to: Michael Ryan
Source: M. Ryan. Footwear and Foot Orthoses. Chapter 5. Home Study Course,
American Physical Therapy Association. 2012 (In Press).
References
The first important piece of information is to compare the differing
rearfoot/forefoot stack heights. The stack height refers to the
amount of midsole and outsole between the foot and the ground.
More material between the foot and the ground may be ideal for
those who still need the shoe to aide in shock absorption during
activity. However, the durometer of this midsole is typically lower
than a traditional athletic shoe, and can be slightly more unstable
depending on the wearer’s mechanics.
http://www.livestrong.com/article/365597-the-effects-of-shoe-weight-onrunning-speed/#ixzz2AhjPCwB2
The rearfoot to forefoot differential gives us our ‘drop’ measurement
with minimalist footwear, ranging anywhere from 0mm to 10mm.
It is important to note that some brands, such as Saucony, have
decreased all their 12mm drop heights to 8mm. When advising
patients on transitioning into minimalist footwear, it’s normal
to have them start with a higher drop value and slowly progress
to a lower drop. A crucial element to success when making the
transition to minimalist footwear is the amount of available ankle
dorsiflexion the client has. If the range is limited by soft tissue, a
stretching regime might be beneficial. If there is a limitation in the
talo-crural joint, a low drop measurement might not be possible.
If the limitation comes from a restriction in the talus’ ability to
glide, this can potentially be mobilized to increase the available
range of motion. Active and passive dorsiflexion testing can help
us determine what type of heel drop they can handle. Those with
Amy Guest, C. Ped (C)
10
http://runsmartproject.com/coaching/2012/02/06/how-much-does-shoe-weightaffect-performance/
Metatarsal Stress Fracture Relating
to Minimalist Footwear – Case
Study
The patient under review is a male in his mid 40s. He is 5’11” and
175lbs. He is an ex-military, who has stayed very fit over the years.
He trains in distance running 4 times per week, and has run 6
marathons in the past. He has used traditional running shoes for
both training and competition.
After a biomechanical assessment, it was determined that he
mildly overpronates, but is otherwise biomechanically sound. He
has shallow, thin, boney feet with limited fatty pads and a dropped
metatarsal arch. He had recently recovered from a stress fracture
of the 2nd metatarsal shaft. It was suggested by his doctor that he
might benefit from use of orthoses. He has never had any issues
with injury in the past.
A Periodical of the Pedorthic Association of Canada
The patient reported that prior to the stress fracture, he had
recently switched from his traditional, neutral running shoes
to a minimal running shoe for training. He immediately started
running in the new footwear with no break-in period. After
some notable pain, an x-ray confirmed that he suffered a stress
fracture to the left, second metatarsal shaft. The client has since
gone back to running in his traditional, neutral running shoes
and hasn’t encountered any problems.
It was confirmed that there were no changes to the client’s
training routines, terrain, distance, or intensity. The only
change to the client’s training regimen was the use of minimal
footwear. The client directly related his recent injury to the
footwear change, and the absence of a break-in period.
With no history of injury, biomechanical abnormalities or
change in training routine, it can only be hypothesized that
there is a strong correlation between the footwear switch and
the metatarsal stress fracture.
Use of Custom Orthotics with
Minimalist Footwear
Crystallee Ripak, C. Ped (C)
Minimalist footwear, and the use of custom made foot
orthoses, both seem to be at different ends of a philosophical
range. When utilizing custom made foot orthoses in minimalist
footwear, there are a few areas to keep in mind that will allow
your patient to have some increased support without totally
giving up the minimalist footwear experience. The areas are
weight, tactile/ground perception, foot strike, and fit.
The minimalist footwear on the market is manufactured to
be as lightweight as possible. The utilization of fabric uppers
and changes to the mid and out sole can aid in achieving the
footwear’s light weight. This lightweight concept can also be
applied to the custom made foot orthoses. Choosing more
lightweight shell materials such as carbon fiber and top cover
materials (1.5mm vs 3mm) can aid in keeping the weight of the
orthoses to a minimum. Decreasing the amount of materials
utilized can also decrease the weight of the device. This can
be accomplished by going from a full-length top cover to a
sulcus length, or three-quarter length. If using a non fulllength custom orthoses, ensure that the transition at the end
of the shell and at the end of the top cover (if using a sulcus
length device) are gradual and smooth to minimize the chance
of any irritation.
Changes to the mid and out sole accomplish some of
the reduction in weight of the shoe, but it also means less
cushioning for the user. This decrease in cushioning allows
for the user to have heightened tactile perception of the
ground. By keeping the top covers of the orthoses thinner,
this increased feedback from the ground can continue to be
facilitated.
11
The importance of fit of footwear is never underestimated by the
Pedorthist. Custom orthoses that have not been manufactured to
be small and lightweight may make it more difficult for a proper
fit to be achieved. A number of minimalist footwear styles are
manufactured to have a barefoot or a snug fit. This essentially
means there will be less room in the shoe to accommodate both
the orthoses and the foot. No cavernous, deep uppers and the lack
of adjustable closures, in some styles, make it more difficult to
accommodate orthoses that may vary too much in size from the
shoe’s original insole. Part of manufacturing slimmer orthoses
could include internal rear and forefoot wedging.
The use of minimalist footwear is also said to encourage a midfoot
strike instead of a rearfoot. The traditional deep heel cups and
rearfoot wedging, that are used widely in the manufacture of
custom foot orthoses of all shapes and sizes, might not provide the
same control and support as they would in a traditional running
shoe.
It is important to keep in mind that minimalist footwear is not for
everyone, just as motion control or stability footwear is not for
everyone. One of the roles that a Pedorthist performs is that of
patient educator. Education about benefits and drawbacks of any
type of footwear will empower patients to make the best decision
for them. By keeping in mind some of the benefits and more
unique features of minimalist footwear - when compared to the
traditional use of custom foot orthoses - it might not become such
a dichotomy.
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The Retail Side of Minimal Shoes
Alex Whyte, C. Ped (C)
As clinical Pedorthists, our treatment plan for patients is focused on
the best possible way we can assist them, using all the tools of our
trade. Unfortunately in the clinic, we only see select populations
who often have painful problems with their feet. Since we primarily
talk to patients who have problems, it can be possible to lose touch
with the general public’s concerns. This could mean individuals
who have a healthy foot type who don’t need the services of a
clinical Pedorthist, but still have questions about minimal running
shoes. Being shoe experts, it is important for a Pedorthist to know
what the general public knows and what the general public is
learning from shoe stores, magazines, and the news about minimal
running shoes.
For Pedorthists without a retail section, it is important to have a
healthy relationship with a local shoe store that can provide the best
service for your clients. This ensures there is no language confusion
between your treatment plan and the shoe store’s fitting technique.
This is also important for sharing education with each other, and
especially educating the public. I interviewed Luke MacDonald,
Partner Owner of Aerobics First in Halifax, Nova Scotia to find out
exactly what the general public thinks about minimal shoes - and,
what shoe stores are doing to teach them.
A little about Luke MacDonald:
As a junior competitive runner, Luke bought his first pair of “real”
running shoes in 1980, the New Balance 620, from Aerobics First.
The store treated him like a king, and he decided that selling shoes
would be a cool job. Starting 2 days after his 16th birthday, Luke
began his career in a little store in Dartmouth, NS called A1 Athleticwear. Now, Luke has been selling shoes for 32 years.
AW: What percentage of all the shoes stocked at Aerobics First are
considered minimal running shoes?
LM: About 5% would be considered minimal by Blaise DuBois or
Daniel Crumback. That said, 70% of those who buy running shoes
from us aren’t actually running. Most are walkers, and simply active
individuals.
Some might argue that minimal is simply less shoe than you have
had before. Transitioning to minimal running shoes is the process
of changing from a heel strike running form, to a midfoot running
form. I will lead a customer to a few paths, and sell shoes based
on their curiosity and willingness to train properly. Then I will set
appropriate distance and speed goals, as well as have a grasp of
their current physical limitations. I advise most to have a physio
assessment by one of the 30 local physiotherapists who attended
“The Prevention of Running Injury” course by Blaise DuBois and
Daniel Crumback.
AW: Would a typical person coming into the store show an interest
in minimal shoes?
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A Periodical of the Pedorthic Association of Canada
LM: Yes, they generally show an interest. If someone said hey, I
don’t know where I should be starting, I would start off with a basic
foot sizing assessment using the Brannock fitting device. I would
ask them if they have researched good form running techniques, or
are they a runner who gets out there for fitness and stress reduction.
If they just want to escape, then I would be more inclined to show
them a traditional shoe. I lean this way, as the size availability for the
average jogger is much greater in traditional shoes than in minimal
models. The fit around the foot is still my number one priority.
Eighty-five percent of people wear their athletic shoes too small.
However, if someone wants to improve their performance and their
skill as a runner, I would introduce them to a more minimal shoe.
WINTER 2013
the military. He then adapted FPI-6 to
create the PesDex, which is a simplified
version for shoe fitters.
AW: What should common shoe stores be teaching the general
public about minimal shoes?
Daniel also introduced us to Baise Dubois, who was facilitating
a 3-day prevention of running injury clinic for physiotherapists. I
was the first running store owner to take the entire course. This
information, combined with understanding basic foot function while
working for Freeman Churchill at Orthotics East, has allowed me to
personally begin running again after believing I was no longer able
to. Last year, I raced a 5k in Austin, Texas and ran 21:30. I simply
ran once a week (5km at 70% effort which was approximately 30
minutes) in the most minimal shoes we have, New Balance MT10.
This year, I plan to do more specific run training and get a little
closer to 20 minutes.
LM: If they are not taking courses and are not invested in it
personally, then they shouldn’t be teaching anything.
If you’re not willing to invest time to learn, then you’re going to get
into a lot of trouble.
If they are invested and willing to be their own guinea pigs, then
the first thing to do is go seek out healthcare professionals who
understand the pros and cons of good midfoot form running. This
was our approach. I saw the tsunami coming 7 years ago and I knew
that we didn’t understand how to sell these shoes. Accordingly, I
waited for the opportunity to be taught properly. Thankfully I met
Major Daniel Crumback, who became our store science mentor.
Daniel used Dr. Anthony Redmond’s FPI-6 (Foot Posture Index) to
aid in guiding members of The Canadian Armed Forces towards
minimal shoes, while reducing the rate of orthotic prescriptions in
AW: When did you start to teach your staff about fitting people for
minimal shoes?
LM: March 2011. That was when we actively began to train staff in
our determination process that we will walk our customers through
if they are going to transition.
AW: This is a tricky question because maybe they don’t like the
shoes at all and they don’t come back to you, but how many people
remain in their minimal shoe after trying it?
15
LM: What we do first is make sure people are very comfortable
coming back to us. One of the things we stress the most is that
minimal shoes are not right for everybody. We tell people to give
it 2 or 3 weeks and within that time, if there is something that is
problematic, to get back in touch with us. We’re very cautious
and understanding that if it doesn’t work, then they need to bring
them back. We really emphasize that. I’d say 75% to 80% will not
necessarily go minimal, but they will start to incorporate a more
minimal type of shoe in their training protocol. Right now there is a
fair amount of rebound where people have gone more minimal, and
then they found it simply did not work for them. So they rebound to
a traditional shoe.
AW: Do you see more competitive or casual runners?
LM: We see both. Some are casual runners who have read about
minimal shoes, and are curious. Others are very injured, and they
think this is their only ticket back. I fall into this type.
AW: Do you encourage teaching people minimal running technique
before going into the shoe, or vice versa?
LM: It works both ways. As we are a shoe store, we encourage
using the proper shoe and always fit the foot first. Anyone can try to
increase their cadence to 175 or 180 while running. A more minimal
shoe will assist them in running at a higher cadence, where a bulkier
shoe will slow down their cadence by promoting a heel strike. But
it is important to note that while training through this process, once
people fatigue while wearing the minimal shoe, they should stop
because it doesn’t have a cushioning safety net for their sloppy heel
strike.
Typically anything over 10km I will encourage a transition shoe, and
I will not likely put the customer in something that is at the far end
of the minimal continuum.
AW: Do you see minimal shoes being a fad, much like the fat
burning rocking shoes?
LM: It was definitely a fad. At the outset, it went into an environment
that didn’t know how to deal with the numbers of people that
were just blindly tossing their regular shoes. There was/is a high
incidence of injury, and there was no guidance from the frontline
(shoe stores). There was the quaint running book, “Born To Run,”
which is an excellent story but is inherently dangerous. People took
to the emotion of running barefoot while not recognizing what they
should do before they toss their old traditional shoes and don the 5
Fingers. They read about the Tarahumara who have been running
like this for centuries, and the readers thought in 3 or 4 runs they
can transition into these ultra distance super athletes - which is
absolutely ridiculous.
Overall, now that the fad is settling out, the opportunity is really
good. More people can become effective with it, as long as they
become smarter and they start to use the gear appropriately by
setting appropriate goals.
AW: So when people come in to try a typical minimal shoe, do they
usually use them on their road runs, trail runs, or treadmill runs?
16
LM: I think trail has been the leader mostly because the books have
been about trail running. Also within trail running itself, because
of the conditions, the minimal shoes seem to have some direct
benefits due to the articulation of the foot. This trend worked well
with trails, then it caught on with road shoes.
AW: What would you teach a part-time high school student working
at a big box store about minimal shoes?
LM: I would teach them foot function and fit first. The bottom line is
that if you don’t know how the foot works in the shoe, the minimal
shoe means nothing. There were a very high percentage of first
runners wearing minimal shoes too small for them. So, it’s hard to
say what caused their injury. It could have been the minimal shoe
or it could have been the fact that they were wearing shoes that
were too small, so the functionality of the foot was restricted within
the shoe. And that’s the piece that was missed by everybody.
If you have more questions you wish to have answered about the retail side of
minimal shoes, I encourage you to visit a local shoe store near you. You will be
glad you did!
Member Profiles:
Jonathan Robinson,
C. Ped Tech (C), C. Ped (C)
Jonathan Robinson, C. Ped Tech (C), C. Ped
(C) got his start in the Pedorthic profession
through a family connection. After moving
to Nova Scotia with his young family
Jonathan was looking for a job that fit
his background as a mechanic. His father
introduced him to Freeman Churchill,
a local Pedorthist and owner of Orthotics East in Halifax. After
working with Freeman one year Jonathan obtained his C. Ped Tech
(C). He remained in Halifax for another year and a half.
In order to get closer to his aging parents, he and his family
relocated to Fredericton, where he qualified for his C. Ped (C) and
two years later opened his business, ABLE Orthotics. Founded in
1997, the lab service started out of his garage, the company has now
expanded to two clinic locations and has five full time employees,
including another Canadian Pedorthist, Jenn Gould, who Jonathan
got to know while volunteering on the PAC Board.
In fact, volunteering with the profession is a passion of Jonathan’s.
He began by serving as ethics chair on the PAC Board for five years
in the mid 90s. This involvement led to him taking on the role of
President-Elect and serving as PAC’s President in 2005-2006.
When describing his time with the PAC Board Jonathan recalls the
immense efforts put in prior to the insurance industry recognizing
pedorthics, and how PAC turned that around. “We’ve really carved
out our niche and have done well to place ourselves as advisors
of choice. We have become respected players in the footcare
community despite the challenges we first faced.”
A Periodical of the Pedorthic Association of Canada
Involvement has helped Jonathan create strong bonds with other
members of the profession. Not just through volunteering but also
at the annual Symposium. Remarking on the openness and the
willingness to share with each other, Jonathan believes that C. Ped
(C)s are extraordinarily helpful and forthcoming with advice on
treatments, business practices and moving the profession forward
as a whole community.
“There is a great continuity in the leadership of both PAC and The
College. People have risen to the challenges of leadership, given
of their time, professionally and personally to ensure that our
profession would thrive. Richard Bosch preceded me as President
of PAC, and Michael Van Vlack came immediately after. I can attest
that they both gave countless hours to the cause, and were excellent
to work with, dedicated and truly selfless in their desire to serve the
membership, and elevate Pedorthics in Canada.“
When asked what he would say to a new member getting started in
the profession Jonathan’s passion and investment as a long time
volunteer is obvious:
“If you had a sense of the historical legacy that we have that has
brought us to this place, you’d understand it’s volunteerism that’s
ensured the job you have now. You have a voice and you have a
role to play in perpetuating the profession and ensuring that we
continue to be a provider of choice for orthotics and footwear. Any
member can find something suited to their interests and strengths.
You can volunteer quietly on a committee or get involved with
leading the profession by volunteering with the board of either PAC
or The College of Pedorthics of Canada.”
After stepping back for a few years, Jonathan has again become
involved with volunteering within the profession, this time with The
College. Currently serving as the Chair, Jonathan says, “I consider
it a privilege to work with such a great group of people that are
typically very helpful and idealistic. I am proud of what Pedorthics
in Canada has become.”
WINTER 2013
profession’s propensity to really grow.
She quickly applied to the Pedorthic
Program at Western University and
became enamored with the practice. “It doesn’t feel like a chore
coming home to study after a day of clinical—I love it!”
Kerrie had known since high school she wanted to work in sports
medicine, “my training in kinesiology was a lot of theory,” she
explains. “I wanted to apply it.” Not to be discredited, Kerrie cites
her kinesiology training, particularly in anatomy, as a big influence
in her study of pedorthics. In fact, she plans to maintain both her
certification as a C. Ped (C) and as a Certified Kinesiologist moving
forward.
A native and current resident of Belmont, Ontario, Kerrie now works
at Foot Dynamics with Linda and Tony Caruana in St. Thomas where
she spends her days sponging up as much as she can. “Every case
stands out to me!” Kerrie replied when asked about memorable
cases. “My experience in the profession is very little so every case
is new and different. Just seeing patients leave the clinic with less
pain than when they came in is so rewarding,” she explains. What
she enjoys most though is being able to help people—and relatively
quickly compared to other similar professions. In conjunction with
her full-time studying, her post at another Dr.’s office, and a local
swim coach, Kerrie stays busy, and deeply immersed in the field.
As for her role at PAC, Kerrie brings a real, genuine enthusiasm
to the profession. She hopes to volunteer with PAC soon, perhaps
once she gains a bit more time back from her studies. “I have to
thank Tony and Linda for everything they’ve taught me in the last
year,” she emphasized. PAC congratulates Kerrie on the recent
passing of her C. Ped (C) exam.
Kerrie Boelsterli, C. Ped (C)
Kerrie joined PAC in July, 2012 and brings
a fresh new face to the profession—very
fresh. In fact, at the time of this writing,
she is waiting to find out if she passed
the final portion of her Canadian Certified
Pedorthist exam.
After graduating from Wilfrid Laurier
University 2010, Kerrie was indeed using her degree, working as
a Kinesiologist, but something was missing. She recalls, “it just
wasn’t really stimulating enough—I wasn’t part of treatment as
much as I wanted to be. I knew I had to go back to school.”
“One day I was on Facebook and I saw an ad for Pedorthics and I
clicked on it.” This prompted her to begin researching the profession
more deeply, speaking with local pedorthists and specialists. Kerrie
is a poster child for the impact digital advertising can have on both
young professionals looking at career choices online, as well as the
www.facebook.com/pedorthic
17
Share your talents –
volunteer with PAC!
Are you looking for a way to contribute to your
Association but not sure where to start? PAC has a
variety of volunteer opportunities that range in time
commitment to suit you and your personal interests.
Professional Development Committee
Do you have a special interest in continued education
in Pedorthics? Join the Professional Development
committee! This committee is responsible for
the oversight and implementation of educational
programs for members and other interested allied
health care providers. This committee reviews the
current needs and interests of the profession and plans
events accordingly. Time commitment would include
committee meetings (via email or teleconference)
and on-site help at local events, varying according to
the number of events planned in the year.
Communications Committee
If you would like to see your work in print, this is
the volunteer position for you. The Communications
Committee is responsible for the publication of the
Pedorthics Quarterly which includes soliciting of
submissions as well as some editorial duties. Those
with a special interest in current pedorthic studies
and issues would be a perfect fit. Time commitment
includes participation in regular meetings (either by
email or teleconference) as well as submission of
original work and vetting the work of others.
Social Media Committee
This committee is responsible for providing
oversight of the Association’s social media strategy
(targeted at consumers) including participation
in social media outlets. Responsibilities vary as
this committee continues to grow and develop, but
current committee members are focused on creating
original blog posts for PAC’s website as well as
materials for the Facebook and LinkedIn pages.
Time commitment includes creation of blog posts as
well as communication by email.
If you are interested in participating on any of
these committees, or would like more information,
contact Kirsten Parker at the PAC office at
kparker@pedorthic.ca
18
A Periodical of the Pedorthic Association of Canada
WINTER 2013
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19
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