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Footwear Science
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Effects of minimalist and traditional running shoes on
injury rates: a pilot randomised controlled trial
Blaise Duboisa, Jean-Francois Esculiera, Pierre Frémonta, Lynne Moorea & Craig Richardsb
a Faculty of Medicine, Laval University, Quebec City, Canada
b Hunter Gait Rehabilitation Clinic, University of Newcastle, Callaghan, Australia
Published online: 10 Jun 2015.
To cite this article: Blaise Dubois, Jean-Francois Esculier, Pierre Frémont, Lynne Moore & Craig Richards (2015): Effects
of minimalist and traditional running shoes on injury rates: a pilot randomised controlled trial, Footwear Science, DOI:
10.1080/19424280.2015.1049300
To link to this article: http://dx.doi.org/10.1080/19424280.2015.1049300
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Effects of minimalist and traditional running shoes on injury rates: a pilot randomised
controlled trial
Blaise Dubois
a
*, Jean-Francois Esculier
a
, Pierre Fr
emont
a
, Lynne Moore
a
and Craig Richards
b
a
Faculty of Medicine, Laval University, Quebec City, Canada;
b
Hunter Gait Rehabilitation Clinic, University of Newcastle,
Callaghan, Australia
(Received 21 December 2014; accepted 5 May 2015)
Despite recent advances in running shoe conception, injuries represent a major concern in the running community. The
objective of this study was to gather the pilot data for a larger randomised controlled trial regarding the effects of
traditional and minimalist shoes on the incidence of running-related injuries (RRI), as well as the rate of adherence to a
running programme. Twenty-six recreational runners were recruited. They were randomly assigned to minimalist (MS) or
traditional (TS) shoes and participated in a 16-week training programme. The information on previously reported risk
factors for RRI was gathered. Participants reported pain and compliance using an online tool. Main outcome measures
included the rates of recruitment, adherence to the programme and programme completion, RRI and the missed training
days secondary to the running-related pain. The recruited runners represented 72.2% of potential participants, among
which 20 (76.9%) completed the programme. Two subjects dropped out before randomisation, plus three in MS and one in
TS during the programme. Rate of adherence was 82.4% in MS and 86.2% in TS. Three runners per group sustained an
RRI (25%, 95% C.I. D9.8%46.7%). Results support the feasibility of a larger scale study. A total of 116 runners would
be needed to detect a clinically significant difference of 20% in injury incidence between MS and TS.
Keywords: running injuries; footwear; prevention; minimalist shoes; traditional shoes
Introduction
Running injuries are a major concern, as between 19.4%
and 79.3% of runners sustain a running-related injury
(RRI) in any given year (van Gent, Siem, van Middel-
koop, van Os, 2007). Although it would be expected that
new technologies developed by footwear companies mini-
mise this issue, there is currently no evidence that they
really prevent injuries (Richards, Magin, & Callister,
2009). Indeed, prescribing traditional running shoes (TS;
characterised by a high cushioning and heel to toe drop,
low flexibility and the presence of motion control and sta-
bility devices) according to the foot shape or degrees of
pronation (Knapik, Trone, Tchandja, & Jones, 2014;
Ryan, Valiant, McDonald, & Tauton, 2011), or the use of
different midsole hardness (Theisen, Malisoux, Genin,
Delattre, & Urhausen, 2014) have failed to decrease the
incidence of injuries. Interestingly, it has even been sug-
gested that wearing TS could increase the likelihood of a
rearfoot strike pattern inducing greater collision forces
during running (Lieberman et al., 2010; Lohman, Balan
Sackiriyas, & Swen, 2011).
Conversely, minimalist shoes (MS; defined as a foot-
wear providing minimal interference with the natural
movement of the foot due to its high flexibility, low heel
to toe drop, weight and stack height, and the absence of
motion control and stability devices) (Esculier, Dubois,
Dionne, & Roy, 2014) have emerged as a modality that
could possibly help to prevent injuries (Goss & Gross,
2012). While a major aim of wearing MS is to promote
better impact moderating behaviours, such as avoidance
of a rearfoot-strike pattern, it seems that the level of mini-
malism might partly explain the likeliness of such kine-
matic and kinetic changes. Indeed, while some studies
have found no significant kinematic changes by wearing
MS (Bonacci et al.2013; Willy & Davis, 2014), others
suggest that changes may be related to the degree of mini-
malism (Squadrone, Rodano, Hamill & Preatoni, 2015)or
to certain shoe characteristics (Horvais & Samozino,
2013; TenBroek, Rodrigues, Frederick, Hamill, 2014).
To date, however, it is not clear whether MS can really
prevent injuries. A recent study suggested that runners
used to wearing TS who transitioned to some specific MS
were prone to a significantly higher risk of injury com-
pared to those who were assigned TS (Ryan, Elashi,
Newsham-West, & Tauton, 2014). Therefore, data com-
paring the effects of MS and TS on RRI rates, regardless
of their previous shoes or the foot shape/mechanics are
needed. The objective of this pilot randomised controlled
*Corresponding author. Email: blaisedubois@me.com
Ó2015 Taylor & Francis
Footwear Science, 2015
http://dx.doi.org/10.1080/19424280.2015.1049300
Downloaded by [132.203.181.24] at 07:17 10 June 2015
trial was to gather the feasibility data and to determine the
sample size needed for a larger study comparing the
effects of TS and MS on the incidence of overuse injuries
in recreational runners.
Methods
Twenty-six recreational runners were recruited via posters
in specialised running stores between March and April
2012. To be included, runners had to be aged between 18
and 55 and be able to run 20 minutes continuously. Exclu-
sion criteria were (1) the presence of an underlying lower
limb degenerative pathology, (2) a past medical history of
lower limb surgery, (3) the use of foot orthotics within the
last six months, (4) a history of lower limb injury in the
six months prior to enrolment and (5) a running experi-
ence of more than one half-marathon or longer distance.
The latter was chosen to control for extensive previous
adaptation for long-distance events. Since our programme
was standardised, runners with more running experience
could have been less likely to develop injuries during this
half marathon training (Nielsen, Buist, Sorensen, Lind &
Rasmussen, 2012). The local university ethics committee
approved this study and all participants signed a detailed
consent form.
At baseline, standard anthropometric measurements
found to be relevant for running injury studies, as well as
information on running and footwear habits were gathered
(Table 1). Running foot strike pattern and step frequency
were determined using a high-definition camera during a
short trial of treadmill running. Using a Nicholas handheld
dynamometer, maximum voluntary isometric contraction
of knee extensors and hip abductors, extensors and exter-
nal rotators were evaluated as described previously (Ber-
ryman Reese, 2005), and converted as per cent of
bodyweight. VO
2
max was then estimated using the
L
egerBoucher test (L
eger & Boucher, 1980).
A random number generator was used to define the
sequence of shoe assignments. Sealed numbered enve-
lopes subsequently assigned participants to a choice of
MS (Inov8 F-Lite 195, Bare X-Lite 150, Road X-Lite
155; Mizuno Wave Universe; Saucony A5) or TS models
(ASICS Cumulus, Landreth, Nimbus; Brooks Defyance,
Ghost, Ravenna; Mizuno Wave Inspire, Wave Rider). An
experienced specialised shoe retailer, who was instructed
not to comment on shoe types, helped select properly fit-
ted shoes within the assigned group. Sealed envelopes
were opened by the retailer, and only the shoe retailer and
one member of the research team (Blaise Dubois) were
aware of the shoe assignation. Thereafter, runners started
the standardised 16-week training programme towards the
completion of a half-marathon (Appendix 1). Participants
were advised not to engage in competitive contact sports
during the study period, so that risks of injuries unrelated
to the running programme were minimised. Data collec-
tion took place between May and August 2012.
Participants completed an online training log in which
they confirmed each training session, reported any pain
during or after training using visual analogue scales and
specified if the experienced pain was related or not to run-
ning. If the log showed irregularities or recurrent pain, a
blinded researcher (Jean-Francois Esculier) contacted the
Table 1. Baseline characteristics of runners.
TS (nD12) MS (nD12)
Gender Female 9 (75) 8 (67)
Male 3 (25) 4 (33)
Age 33.7 §7.8 29.8 §8.7
BMI (kg/m
2
) 24.1 §3.4 24.8 §3.6
Running experience (years) 3.4 §3.9 1.9 §3.2
Step frequency (steps/min) 166.0 §7.6 165.3 §14.9
VO
2
max (ml/kg/min) 47.0 §6.2 45.4 §7.4
Foot strike pattern Rearfoot 10 (83) 8 (67)
Midfoot 1 (9) 1 (9)
Forefoot 1 (9) 3 (25)
Shoes prior to study Traditional 8 (67) 10 (83)
Minimalist 4 (33) 2 (17)
Muscle strength (%BW) Left Right Left Right
Knee Ext 66.5 §19.1 67.0 §19.1 62.0 §14.3 63.5 §14.5
Hip Abd 33.7 §6.8 40.4 §11.6 34.2 §10.1 36.9 §13.1
Hip ER 15.0 §5.9 11.8 §2.4 15.2 §5.9 14.2 §4.7
Hip Ext 60.0 §20.2 59.0 §20.4 54.8 §22.1 57.0 §23.7
Note: Units are expressed as n(%) or mean §SD. No significant between-group differences were observed. TS: traditional shoes; MS: minimalist shoes;
BMI: body mass index; BW: bodyweight.
2B. Dubois et al.
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participant and an appointment with a sport medicine phy-
sician (Pierre Fr
emont) and a physical therapist (Jean-
Francois Esculier) specialised in running injuries was
scheduled. Both clinicians were blinded to the assigned
group and participants were instructed not to bring or
mention the assigned footwear during evaluations. The
sport physician and the physical therapist completed a
standardised evaluation sheet to establish diagnosis and
recommend actions and/or treatments. Following the pro-
gramme, participants were asked if they were satisfied or
not with their shoes. To minimise drop-out rates, ques-
tions or injuries were managed rapidly through direct con-
tact with investigators during the study period.
The rate of adherence in each group was defined as the
proportion of running sessions performed out of the total
training sessions planned in the standardised programme.
In the event of a dropout, training sessions completed
prior to the dropout date were considered. RRI was
defined as (1) any period of three or more training days
that were either missed or decreased by at least 50%
because of pain, or (2) a diagnosis of RRI following eval-
uation by the health professionals. In addition, runners
reporting levels of pain 4/10 without being forced to
miss or decrease the training were also referred to the
sport physician to establish whether an RRI was present.
To our knowledge, no strong data regarding differen-
ces in RRI incidence in MS and TS have been published.
Therefore, we used an expert consensus (Blaise Dubois,
Jean-Francois Esculier, Pierre Fr
emont, Craig Richards)
to define a clinically significant between-group difference
in RRI of 20%. This difference was then used for the cal-
culation of sample size needed for the larger study.
Data analysis
Feasibility was assessed based on the recruitment capac-
ity, online tool efficiency, as well as the rates of comple-
tion, injury and adherence to the running programme. The
sample size needed for a larger study was calculated based
on the following: a power of 80%, a two-sided compari-
son of proportions with an alpha of 5% in addition to
injury and dropout rates from this pilot study (Whitley &
Ball, 2002), as well as running injury rates previously
reported by van Gent et al., (2007). To compare partici-
pant baseline characteristics including age, gender and ini-
tial anthropometric, physiological and biomechanical
measurements across randomisation groups, we used the
Wilcoxon rank sum test for continuous variables and Fish-
er’s exact test for categorical variables (Armitage, Berry,
& Matthews, 2001). Between-group completion and
injury incidence proportions were compared using Fish-
er’s exact test. Adherence to the training programme and
the average number of training sessions that were either
missed or reduced by at least 50% because of the pain
were compared using repeated measures analysis in a
logistic generalised estimating equations framework
(Hanley, Negassa, deB. Edwardes, & Forrester, 2003).
The level of statistical significance was set at P<0.05.
Results
Initially, 36 potential subjects contacted the research team
by phone, of which 26 (72.2%) were eligible based on the
study criteria. After the withdrawal of 2 subjects prior to
randomisation and dropout of 4 others during the study
period (1 in TS, 3 in MS), twenty participants (76.9%)
completed the study (Figure 1). Rate of adherence to the
running programme was 86.2% in TS and 82.4% in MS
(Table 2).
No baseline differences were observed between
groups for demographic or running gait characteristics
(P0.136; Table 1). During the study period, six runners
(25%, 95% CI D9.8%-46.7%) received a diagnosis of
RRI. Injuries in the MS group were a metatarsal stress
fracture, iliotibial band syndrome and plantar fasciitis.
Those in the TS group were non-specific low back pain
and two medial tibial stress syndromes.
Missed training days because of the pain related to
running were similar across groups (Table 2). A signifi-
cantly higher number of missed training days because of
the pain unrelated to running was reported in MS. The
specific causes reported were muscle contusion, muscle
strain, ankle sprain and hemorrhoids that were sustained
at work or during soccer, climbing or karate. Following
completion of the training, a majority of runners reported
being satisfied with the shoes they received (Table 2).
Based on the injury incidence of 25% and 45% in both
groups and dropout rate of 23.1%, a total of 116 subjects
per group would be needed to detect a clinically signifi-
cant difference of 20% in injury incidence between MS
and TS in a definitive study.
Discussion
The protocol used in this study was shown to be feasible
on a larger scale based on the highly effective rate of
recruitment, low loss to follow-up and the sample size
estimation. As expected, the small number of participants
in this pilot study did not allow us to determine whether
the use of MS or TS affects the incidence of running inju-
ries. The dropout rate following randomisation (17%) was
moderate compared to other similar studies in which drop-
out rates of 23% (Ryan et al., 2011) and 13% (Ryan et al.,
2014) were observed. However, compared to previously
reported injury rates (van Gent et al., 2007), a relatively
low incidence of injuries was observed during the course
of the running programme used in this study. This might
be explained by the fact that the programme was built to
expose runners to a very gradual increase in running
Footwear Science 3
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mileage and intensity to minimise the influence of training
errors on injury rates.
In this study, runners were included regardless of the
foot shape or the previous footwear. In contrast, Ryan et al.
(2014) restricted inclusion to runners used to running with
TS, which may have led to injuries that were related to tran-
sition from one shoe type to another rather than on the shoe
type itself. In addition, only experienced runners able to run
for at least one hour participated in the study of Ryan et al.
(2014). This study included participants on the basis of a
limited experience of ‘no more than one previous experi-
ence with half-marathon and no experience with longer
runs’ and capacity to run for at least 20 minutes. Further-
more, we decided to allow a self-selection of shoes by par-
ticipants among pre-determined options. Our rationale was
that comfort is a key when aiming to minimise the probabi-
lity of injuries due to an inappropriate shoe fitting, and that
it represents one of the most influential factors for runners
when selecting running shoes. We believe that these criteria
Table 2. Injuries and online tool results during the running
programme.
TS (nD12) MS (nD12) P-value
RRI 3 (25.0) 3 (25.0) 1.000-
y
Missed trainings
Pain related to running
programme
24 (2.6) 23 (2.8) 0.646z
Pain unrelated to
running programme
4 (0.4) 18 (2.2) 0.221z
Satisfaction about shoes 8 (66.7) 11 (91.7) 0.3
y
Dropouts 1 (8.3) 3 (25.0) 0.6-
y
Adherence rate 790 (86.2) 669 (82.4) 0.8z
Note: Units are expressed as n(%). TS: traditional shoes; MS: minimalist
shoes; RRI: running-related injury;
y
Fisher’s exact test; zgeneralised estimating equations; total number of
trainings was 812 on MS and 917 on TS.
Figure 1. Flow diagram of participants. TS: traditional shoes; MS: minimalist shoes.
4B. Dubois et al.
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increase the external validity of our study as it better reflects
the characteristics of a recreational population getting
involved with running objectives that require structured
training with a higher risk of injury.
The results show that the protocol used in this study
could enable us to further analyse the influence of running
shoe type on injury incidence in a cohort that is represen-
tative of a general running population; however, such pro-
tocol does have limitations. First, it is impossible to
prevent runners from knowing what type of shoe they are
assigned; therefore, a double-blind design is not feasible
in this type of study. Second, it would have been interest-
ing to document potential effects of shoe type on the foot
strike pattern and step frequency. Indeed, this could
potentially relate to the development of a specific RRI.
However, in a definitive study, such effects could easily
be observed by repeating the running assessment at the
end of the training. Finally, running assessments were per-
formed on a treadmill, which has been suggested to poten-
tially alter foot kinematics (Nigg, De Boer, & Fisher,
1995). Thus, overground running assessments should be
preferred in a full clinical trial.
Conclusion
Results from this pilot study support the feasibility of
a larger study, based on a satisfactory recruitment rate,
efficiency of the online data collection tool, low attrition as
well as high adherence rate. Randomising runners, without
limiting the sample to previous shoe types, foot shapes or
extensive running experience, improves the external valid-
ity. A total of 116 subjects per group would be needed to
detect a clinically significant difference of 20% in injury
incidence between MS and TS in a definitive study.
Acknowledgements
Authors would like to thank the Canadian Academy of Sport and
Exercise Medicine for funding this study.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
This study was funded by a grant from the 2011 Canadian Acad-
emy of Sport and Exercise Medicine research programme.
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Appendix 1. Running programme
Weeks Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
13x(1
0/10)4x(1
0/10)5x(1
0/10)6x(1
0/10) Rest 7x (10/10)8x(1
0/10)
2 Rest 9x (10/10) 10x (10/10)3x(2
0/10) Rest 4x (20/10)5x(2
0/10)
3 Rest 3x (30/10)4x(3
0/10)3x(4
0/10) Rest 4x (40/10)4x(5
0/10)
4 Rest 2x (20/10)C1504x (40/10) Rest 1504km
5 Rest 2x (20/10)C1505x (40/10) Rest 1505km
6 Rest 3x (20/10)C2006x (40/10) Rest 1506km
7 Rest 3x (20/10)C2003x (30/10)CRest 2007km
8 Rest 4x (20/10)C2004x (30/10)CRest 2008km
9 Rest 4x (20/10)C2503x (40/10)CRest 20010 km
10 Rest 5x (20/10)C2504x (40/10)CRest 20012 km
11 Rest 5x (20/10)C3003x (50/10)CRest 20010 km
12 Rest 6x (20/10)C3004x (50/10)CRest 20014 km
13 Rest 6x (20/10)C3003x (60/10)CRest 20016 km
14 Rest 7x (20/10)C3004x (60/10)CRest 20018 km
15 Rest 7x (20/10)C3003x (70/10)CRest 20016 km
16 Rest 5x (20/10)C300Rest Rest 200
1
/
2
marathon
Note: C: add 10 minutes of slow jogging before and 5 minutes following these training sessions, which must be done at faster than usual pace.
(20/10): indicates that after 2 minutes of running, there is 1 minute of walking.
6B. Dubois et al.
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