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Injury risk in runners using standard or motion control shoes: A randomised controlled trial with participant and assessor blinding

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Background/aim: This randomised controlled trial investigated if the usage of running shoes with a motion control system modifies injury risk in regular leisure-time runners compared to standard shoes, and if this influence depends on foot morphology. Methods: Recreational runners (n=372) were given either the motion control or the standard version of a regular running shoe model and were followed up for 6 months regarding running activity and injury. Foot morphology was analysed using the Foot Posture Index method. Cox regression analyses were used to compare injury risk between the two groups, based on HRs and their 95% CIs, controlling for potential confounders. Stratified analyses were conducted to evaluate the effect of motion control system in runners with supinated, neutral and pronated feet. Results: The overall injury risk was lower among the participants who had received motion control shoes (HR=0.55; 95% CI 0.36 to 0.85) compared to those receiving standard shoes. This positive effect was only observed in the stratum of runners with pronated feet (n=94; HR=0.34; 95% CI 0.13 to 0.84); there was no difference in runners with neutral (n=218; HR=0.78; 95% CI 0.44 to 1.37) or supinated feet (n=60; HR=0.59; 95% CI 0.20 to 1.73). Runners with pronated feet using standard shoes had a higher injury risk compared to those with neutral feet (HR=1.80; 95% CI 1.01 to 3.22). Conclusions: The overall injury risk was lower in participants who had received motion control shoes. Based on secondary analysis, those with pronated feet may benefit most from this shoe type.
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Injury risk in runners using standard or motion
control shoes: a randomised controlled trial with
participant and assessor blinding
Laurent Malisoux,
1
Nicolas Chambon,
2
Nicolas Delattre,
2
Nils Gueguen,
2
Axel Urhausen,
1,3
Daniel Theisen
1
Additional material is
published online only. To view
please visit the journal online
(http://dx.doi.org/10.1136/
bjsports-2015-095031).
1
Sports Medicine Research
Laboratory, Luxembourg
Institute of Health,
Luxembourg, Luxembourg
2
Decathlon, Movement
Sciences Department,
Villeneuve dAscq, France
3
Sports Clinic, Centre
Hospitalier de Luxembourg,
Luxembourg, Luxembourg
Correspondence to
Dr Laurent Malisoux, Sports
Medicine Research Laboratory,
Luxembourg Institute of
Health, 76 rue dEich,
Luxembourg, L-1460
Luxembourg; laurent.
malisoux@lih.lu
Accepted 16 November 2015
To cite: Malisoux L,
Chambon N, Delattre N,
et al.Br J Sports Med
Published Online First:
[please include Day Month
Year] doi:10.1136/bjsports-
2015-095031
ABSTRACT
Background/aim This randomised controlled trial
investigated if the usage of running shoes with a motion
control system modies injury risk in regular leisure-time
runners compared to standard shoes, and if this
inuence depends on foot morphology.
Methods Recreational runners (n=372) were given
either the motion control or the standard version of a
regular running shoe model and were followed up for
6 months regarding running activity and injury. Foot
morphology was analysed using the Foot Posture Index
method. Cox regression analyses were used to compare
injury risk between the two groups, based on HRs and
their 95% CIs, controlling for potential confounders.
Stratied analyses were conducted to evaluate the effect
of motion control system in runners with supinated,
neutral and pronated feet.
Results The overall injury risk was lower among the
participants who had received motion control shoes
(HR=0.55; 95% CI 0.36 to 0.85) compared to those
receiving standard shoes. This positive effect was only
observed in the stratum of runners with pronated feet
(n=94; HR=0.34; 95% CI 0.13 to 0.84); there was no
difference in runners with neutral (n=218; HR=0.78;
95% CI 0.44 to 1.37) or supinated feet (n=60;
HR=0.59; 95% CI 0.20 to 1.73). Runners with pronated
feet using standard shoes had a higher injury risk
compared to those with neutral feet (HR=1.80; 95% CI
1.01 to 3.22).
Conclusions The overall injury risk was lower in
participants who had received motion control shoes.
Based on secondary analysis, those with pronated feet
may benet most from this shoe type.
INTRODUCTION
Several hundred running shoe models are currently
available in the market. Notwithstanding the
increasing focus on running shoe design, technolo-
gies and function, running-related injury incidence
has not changed noticeably over the last few
decades.
1
Various biomechanical variables such as
strike pattern,
2
impact forces,
3
foot posture or foot
pronation,
45
have all been proposed as injury risk
factors. Footwear features such as cushioning tech-
nology, stability and motion control systems
(motion control shoes), have been designed to miti-
gate against these risk factors and are extensively
used as selling points by shoe manufacturers.
Foot posture is believed by some to be a risk
factor for injury.
5
This often results in attempts to
match footwear to a runners foot morphology,
despite an absence of evidence to suggest this
approach will reduce injuries.
46
Specically,
motion control shoes are typically prescribed to
runners with pronated feet, while neutral stability
shoes are recommended to individuals with neutral
feet and cushioned shoes to those with supinated
feet. Several studies have been unable to demon-
strate the benet of the above-described prescrip-
tion strategy,
710
although they were either
inadequately powered,
9
or performed in a military
population,
78
limiting the applicability of ndings
to distance runners.
4
Furthermore, a more pro-
nated foot posture was reported not to be asso-
ciated with injury risk in a prospective cohort study
on over 900 novice runners,
11
questioning the use
of running shoes featuring motion control systems
designed to reduce foot pronation. Running in
shoes equipped with that technology increased the
risk of experiencing running-related pain.
9
Although these results are preliminary, it is worry-
ing that a signicant proportion of running shoes
have motion control, a fact that many runners may
not be aware of when buying their shoes.
Therefore, in this study, we (1) investigated
whether running shoes equipped with motion
control features modied injury risk in regular
leisure-time runners and (2) if this inuence
depended on foot morphology. Our main hypoth-
esis was that injury risk would be different when
running in shoes with motion control compared
with standard (neutral) shoes, while controlling for
the potential confounders. Our secondary hypoth-
esis was that the difference in injury risk would
depend on foot morphology.
MATERIALS AND METHODS
Participants and study design
This randomised controlled trial (unregistered)
recruited recreational runners, regardless of tness
level. Reporting of the study followed the
CONSORT statement.
12
Given an expected injury
rate of 22% and 35% in the two groups,
9
respect-
ively, and a desired power of 0.8 and an α-level of
0.05, a total of 364 runners were required to test
our main hypothesis. All participants received a full
description of the study protocol and provided
written informed consent for participation. All pro-
cedures were approved by the National Ethics
Committee for Research (ref 201211/04).
Participants were recruited via advertisements in
local newspapers and on specialised internet sites
from March to April 2014. Following online regis-
tration, participants were contacted by phone to
verify inclusion criteria: healthy, aged 1865 years,
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regular running (at least 1 session/week) for at least 6 months
over the 12 months prior to the study, no contraindication to
perform running activity, no prior (<12 months) surgery at the
lower limbs or lower back region, and no use of orthopaedic
insoles for running activities. Volunteers were also required to
perform at least one running activity per week during the
6-month follow-up period (from June to December), to use the
provided study shoes for all running activities, and to report, at
least once per week, all sports activities and injury or pain
experienced during the follow-up.
Individuals reported to the laboratory for eligibility check and
baseline assessment. A questionnaire gathered information about
age, sex, running regularity over the previous 12 months
(months of practice), running experience (years of regular prac-
tice) and previous injury to the lower back or lower limbs pre-
venting normal running activity during the preceding
12 months. Foot posture was assessed using the six-item Foot
Posture Index (FPI), previously proven to be valid.
13 14
Normative values presented by Redmond et al
15
were used as
references to categorise each foot into one of the ve categories
(highly supinated, supinated, neutral, pronated and highly pro-
nated) based on their FPI score. Two previously trained apprai-
sers performed all evaluations and assessed the rst 50
participants together to optimise consistency. Subsequently, high
inter-rater agreement for classifying the runners in one of the
ve categories was found based on a further 40 participants,
with a Cohensκcoefcient of 0.86. Since the unit of analysis is
the participant, the classication into one of the ve categories
was based on the foot with the most extreme score.
Study shoes characteristics
Two versions (motion control and standard) of a running shoe
model were provided for the trial by a renowned sport equip-
ment manufacturer. Shoes were de-identied so the study parti-
cipants did not know which brand they were given. The motion
control shoes and standard shoes both had a heel-to-toe drop of
10 mm and were derived from a commercially available model.
Motion control shoes were characterised by (1) a thermoplastic
polyurethane structure located at the medial part of the midfoot
and (2) a dual-density ethyl-vinyl-acetate (EVA) midsole located
at the forefoot (gure 1). Apart from these features, the two
versions were identical, so participants did not know which type
of shoe they used.
A subset of each version was characterised regarding midsole
hardness difference between the medial and the lateral part of
the midsole, using an Asker-C durometer according to the
standard JIS K 7312 protocol for hardness characterisation of
viscoelastic polymers (average value of 5 independent measures/
shoe; 12 shoes tested/model). The measure was taken perpen-
dicularly to the frontal plan, with the shoes cut at the level of
the rst metatarsal head.
Participants were randomly allocated to one of the two shoe
models in accordance with stratication by potential confoun-
ders (age and body mass index (BMI); cut-off values are
medians)
16
and foot morphology. Participants and assessors
involved in the shoe distribution and participant follow-up were
both blinded regarding the shoe allocation. Each shoe pair was
coded by a coworker not involved in the study prior to the dis-
tribution. The code was broken after completion of data
collection.
Data collection during follow-up
A dedicated internet-based platform (http://www.tipps.lu,
Training and Injury Prevention Platform for Sports) was used to
collect all information of the participants pertaining to their
sports participation and any adverse events (injuries, pains and
illnesses).
1719
Training sessions were characterised by the type
of activity, context, duration, subjectively perceived intensity
measured using the Borg CR-10 scale,
20
distance covered,
running surface and shoes worn. Whether participants experi-
enced any pain during the session forcing him/her to reduce
volume or intensity, or to interrupt the practice, was also
reported. The response to each item was mandatory for every
declared training session or competition and could be selected
from a predened list.
Injury was self-reported and dened as any physical pain
located at the lower limbs or lower back region, sustained
during or as a result of running practice, and impeding planned
running activity for at least 1 day (time-loss denition). The
online injury questionnaire has been previously described.
21
Injuries were classied according to consensus guidelines on
sports injury surveillance studies.
22 23
Self-reported data on every injury were systematically checked
by the principle investigator for completeness and coherence.
Participants who did not complete their entire running calendar
with weekly information were contacted by one of the investiga-
tors to ensure that injury was not the reason for non-
compliance. A participant was considered as dropping out of
the study when no data had been uploaded in the system for
more than 2 weeks despite an automatic email reminder and a
phone call from the research team. At the end of the study
(December 2014), the participants were invited for a nal visit
to check all injury data, compliance and shoe use.
Statistical analyses
Descriptive data for the shoe properties, as well as the personal
and training-related characteristics are presented as count and
percentage for dichotomous variables, and as mean and SD, or
as median and range, respectively, for normally and abnormally
distributed continuous variables. Average sport-related character-
istics were computed for each participant over their specic
period of observation. Lateral and medial midsole densities of
both models were analysed using a Students t test.
To address the rst objective, unadjusted Cox proportional
hazard regressions were performed to present the crude esti-
mates of hazard ration (HR) for shoe version and other poten-
tial risk factors. Date at inclusion (shoe distribution date) and
date at injury or at censoring were basic data used to calculate
the time at risk. A participant was right-censored, yet included
in the analyses, in case of severe disease, non-injury causing a
modication of the running plan or at the end of follow-up
(shoe return date), whichever came rst. Time at risk was
expressed in hours spent running and used as the time scale. To
validate the statistical model, the assumption of proportional
hazards was evaluated by log-minus-log plots. The variables
with a p value <0.200 were included in the adjusted Cox
regression analysis to determine if the use of motion control
shoes is associated with injury risk, regardless of runnersfoot
morphology, and controlling for potential confounders. The rec-
ommendation of using at least 10 injuries per predictor variable
included in the Cox regression analysis was strictly followed.
24
To address the second objective, a stratied analysis was per-
formed to investigate the interaction between shoe version and
foot morphology. HRs and their 95% CIs were determined for
different foot morphology strata, with a single reference cat-
egory (the stratum of runners with neutral feet, using neutral
shoes).
25 26
HR and the corresponding 95% CI were computed
within strata of foot type to determine the effect of the shoe
2 Malisoux L, et al.Br J Sports Med 2016;0:17. doi:10.1136/bjsports-2015-095031
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model within each strata. Signicance was accepted for p<0.05.
All analyses were performed using SPSS V.20.
RESULTS
Participants
A total of 423 eligible volunteers came to the laboratory for the
initial visit and shoe order. Thirty-seven participants did not
retrieve their running shoes because of injuries (n=11) or other
health problems (n=5) during the production period, lack of
interest to participate (n=17) or withdrawal for personal
reasons (n=4). A total of 386 pairs of running shoes were thus
distributed. After shoe distribution, 14 participants were
excluded from the analysis because they did not upload any
training data (n=8), had not used the study shoes for more than
2 sessions (n=5) or had health problems unrelated to running
(n=1). In total, 51 participants (gure 2) with similar demo-
graphics and foot type distribution to those of the nal sample
were excluded from the analyses (see online supplementary
table S1).
A total of 12 558 running sessions were recorded for a dis-
tance of 116 723 km and 12 094 h run. Table 1 illustrates the
characteristics of the two study groups, which both had a high
compliance regarding the use of the provided study shoes. The
average data uploading delay was 4 days. Since there were few
participants with hyperpronated and hypersupinated feet, these
categories were merged with those of pronated and supinated
feet, respectively.
Shoe characteristics
In motion control shoes, the midsole hardness was 15% higher
(p<0.001) in the medial part compared to the lateral part
(Asker C values 60±2 and 51±2, respectively), while there was
no difference in standard shoes (51±3 and 51±2, respectively).
Injuries
An injury was sustained by 93 participants (25%) during the
follow-up. The overall incidence was 7.69 injuries/1000 h of
exposure (95% CI 6.28 to 9.41). There were 32.4% of partici-
pants injured in the standard shoe group and 17.6% in the
motion control shoe group (RR=0.54, 95% CI 0.37 to 0.79).
More details on the rst-time injury characteristics are presented
in table 2.
Primary analysis
Overall, the injury risk was lower among the participants who
had received motion control shoes (p=0.005; table 3). Both the
unadjusted and the adjusted model revealed that previous injury
was a risk factor (p<0.001). Additionally, BMI, running regular-
ity and mean session distance were associated with injury risk,
but only in the unadjusted model. Both models yielded very
similar estimates for the shoe version. Thus, crude estimates
were used in the secondary analyses.
Secondary analysis
In the subgroup of runners with pronated feet (n=94), the rate
at which the injuries occurred was signicantly lower among the
participants using the motion control shoes (HR=0.34; 95% CI
0.13 to 0.84; bottom line of table 4). This difference was not
observed in runners with neutral (HR=0.78; 95% CI 0.44 to
1.37) or supinated feet (HR=0.59; 95% CI 0.20 to 1.73). No
difference was found between the strata regarding the principle
confounders (see online supplementary table S2). Interestingly,
among the participants who received standard shoes, the rate at
which the injuries occurred was signicantly higher in the group
of runners with pronated feet compared to runners with neutral
feet (HR=1.80, 95% CI 1.01 to 3.22). In the group of partici-
pants with pronated feet, 25 had one foot classied as neutral.
A sensitivity analysis showed that reclassifying these runners
into the group with neutral feet did not affect the results.
DISCUSSION
This is the rst large-scale prospective cohort study to investigate
the effectiveness of motion control shoes on injury risk among
regular leisure-time runners. We found that running in shoes with
Figure 1 Illustration of the two
technical features (coloured in black
for illustration purposes) designed to
limit the pronation movement of the
runners. (A) Represents a piece of rigid
plastic (thermoplastic polyurethane)
located on the medial side, under the
midfoot at the midsole edge. (B) Area
of the harder midsole EVA
(ethylene-vinyl acetate) foam. These
elements were not recognisable on the
shoe version distributed.
Malisoux L, et al.Br J Sports Med 2016;0:17. doi:10.1136/bjsports-2015-095031 3
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motion control was associated with a signicantly lower overall
injury risk, thus conrming our main hypothesis. However, in
accordance with our secondary hypothesis, this general protective
effect of motion control shoes was demonstrated only in runners
with pronated feet, while those with neutral or supinated feet did
not benet from this technology. In addition, the stratied analysis
revealed that, among the runners who received the standard shoes,
those with pronated feet had a higher injury risk than those with
neutral feet (table 4). Nevertheless, these secondary ndings must
be viewed as preliminary and need to be veried by further
research including a larger sample size.
Matching running shoes to foot type?
The injury incidence reported in the present study (7.7 injuries/
1000 h of running) was consistent with previous results from
our laboratory and a meta-analysis (6.7 and 7.7 RRI/1000 h,
respectively).
26 27
The inuence of shoe technology on injury
risk in our study may appear inconsistent with some prior
research. However, differences in study design, population and
shoe characteristics must be considered. Previous studies in mili-
tary populations
68
and female runners
9
have investigated the
effectiveness of matching running shoes according to foot
shape, but none found evidence for pronating runners to be
advised to wear antipronation shoes.
Importantly, however, the study series by Knapik et al
68
focused on military populations where recruits are exposed to
high training loads during activities other than running,
meaning ndings may not necessarily be extrapolated to recre-
ational runners. The study by Ryan et al
9
involving female
runners analysed the effect of three levels of footwear stability
on pain outcomes. However, the participants were not blinded
and their nal sample size was small (n=81). Additionally, the
study groups were not equivalent regarding body mass and
running experience, two potential confounders. Furthermore,
the neutralrunning shoe used in their study (Pegasus, Nike)
actually possesses motion control features, including a thermo-
plastic midfoot shank and a lateral sole are. This illustrates that
shoes from different brands presented as neutral may not be
identical, and that care must be taken when drawing conclusions
from studies that have used different shoe models.
A large prospective cohort study (DANORUN) in novice
runners using neutral shoes previously questioned the belief that
a pronated foot posture is a risk factor for injury.
11
Indeed, that
study revealed that runners with pronated feet were at a similar
risk of injury compared to those with neutral feet. Contrastingly,
Figure 2 Flow chart of volunteers and study participants.
4 Malisoux L, et al.Br J Sports Med 2016;0:17. doi:10.1136/bjsports-2015-095031
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we observed a higher injury risk in our subgroup possessing a
more pronated foot posture. However, our target population
(more experienced and regular runners) and shoe brand used
were different. Since the DANORUN and the present study are
currently the only ones to investigate the association between
foot morphology and injury risk, further research is required to
explain this apparent discrepancy and to reach a nal
conclusion.
Clinical implications
Runners have used cushioned shoes for only four decades,
which contrasts with the long-term anatomical and neuromo-
tor adaptations brought about by millions of years while
running barefoot or in minimal footwear.
3
One of the main
characteristics of modern shoes is their cushioning properties
aiming to increase the comfort and decrease the impact force
at touchdown.
28
However, the softer the sole of the shoe, the
greater the risk of overpronation movement.
29
A previous
study already suggested that a certain degree of additional sta-
bility may be benecial even for those individuals with
neutral foot posture.
9
This could be especially true for shoes
with soft midsoles. The shoes used in the present study had
an overall stiffness that was probably located within the lower
1015% range of commonly available models, according to
data from Shorten and Mientjes
30
and those from our previ-
ous study.
18
One might speculate that runners with pronated feet were
insufciently stabilised with the current standard shoe version
and that additional motion control could be achieved with the
motion control shoe version. The fact that motion control
shoes are effective in controlling foot pronation, especially
footwear with dual midsole materials used in this study,
31
sup-
ports this argument. We observed that runners with pronated
feet were protected when running in motion control shoes and
that they were exposed to a greater injury risk when using the
standard shoes. Unfortunately, in the absence of biomechanical
data, the mechanisms involved in the injuries observed in our
study are unclear. Future research should investigate what
degree of motion control is needed in our modern cushioned
shoes with regard to foot morphology and other footwear
properties.
Strengths and limitations
Strengths of this study include the randomised controlled
design with participant and assessor blinding, a stratied ran-
domisation and a prospective follow-up over 6 months, plus
the fact that the two running shoe versions were strictly
similar except for the motion control features. A major
Table 1 Participantscharacteristics and sport participation
pattern for both study groups
Characteristics Unit/qualifier
Standard
shoes
(n=185)
Motion
control
shoes
(n=187)
Participantscharacteristics
Age Years 41.0±11.2 39.9±9.7
Sex Male 113 (61%) 111 (59%)
Female 72 (39%) 76 (41%)
BMI kg/m
2
23.7±3.0 23.6±3.1
Previous injury Yes 137 (74.1%) 143 (76.5%)
No 48 (25.9%) 44 (23.5%)
Running experience Years 7 [045] 5 [037]
Regularity
(last 12 months)
Months 12 [612] 12 [312]
Foot morphology Hypersupinated 5 (2.7%) 5 (2.7%)
Supinated 25 (13.5%) 25 (13.4%)
Neutral 108 (58.4%) 110 (58.8%)
Pronated 39 (21.1%) 41 (21.9%)
Hyperpronated 8 (4.3%) 6 (3.2%)
Sport participation pattern
Sessions run with study
shoes
% of total
sessions
95.1±11.8 94.9±10.6
Other sports Sessions/week 1.0±1.5 0.9±1.3
Running frequency Sessions/week 1.9±0.9 1.9±1.3
Mean session duration min 56±15 57±43
Mean session distance km 9.0±2.6 8.7±3.4
Mean session intensity au 3.8±1.0 3.7±1.0
Mean speed Km/h 9.7±1.2 9.6±1.4
Runs on hard surface % of total
sessions
60.4±31.2 58.3±33.6
Competition % of total
volume
1.9±3.4 2.4±7.8
au, arbitrary unit; BMI, body mass index.
Table 2 Characteristics of self-reported first-time running-related
injuries for each study group (n=93)
Standard shoes
Motion control
shoes
N Per cent N Per cent
Injury location
Lower back region/pelvis 2 3.3 0 0
Hip/groin 5 8.3 1 3
Thigh 5 8.3 4 12.1
Knee 10 16.7 7 21.2
Lower leg 16 26.7 7 21.2
Ankle 13 21.7 10 30.3
Foot 8 13.3 4 12.1
Toe 1 1.7 0 0
Injury type
Tendon 25 41.7 17 51.5
Muscle 18 30 9 27.3
Capsules and ligaments 8 13.3 5 15.2
Bone structures 5 8.3 1 3
Other joint structures 2 3.3 1 3
Other injury/unknown 2 3.4 0 0
Injury severity
Slight (03 days) 16 26.7 7 21.2
Minor (47 days) 4 6.7 8 24.2
Moderate (828 days) 25 41.7 12 36.4
Major (>28 days) 15 25 6 18.2
Recurrence
No 32 53.3 22 66.7
Yes 28 46.7 11 33.3
Injury category
Acute 13 21.7 8 24.2
Progressive 47 78.3 25 75.8
Self-reported injuries were classified according to consensus guidelines for sports
injury surveillance studies.
21 22
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limitation is that too few runners with highly supinated or
highly pronated feet participated in the study, thus not allow-
ing analyses of these subgroups. Additionally, the absence of
signicant results for runners with supinated and neutral foot
types may be due to the low sample size, since the study was
not powered for these secondary analyses. This limitation is
highlighted by the small number of events observed in the
stratum of runners with supinated feet, indicating that these
results should be considered with caution (table 4). Given
that the participants were asked to use the study shoes for all
their running sessions, those runners preferring to use more
than one shoe pair may have been reluctant to register. Thus,
the volunteers included in this study may not represent all
recreational runners. Another aspect of this study is that only
one shoe model was tested regarding the effect of motion
control technology. Therefore, our results may not be gener-
alisable to other shoe models or brands.
Summary
The overall injury risk was lower among the participants who
had received motion control shoes. Based on secondary analysis,
it appears that runners with pronated feet may benet most
from this shoe type.
What are the new ndings?
In recreational runners, the use of motion control shoes was
associated with lower injury risk compared to standard shoes.
Among the runners using standard shoes, those with
pronated feet were at a higher risk of injury compared to
those with neutral feet.
Runners with pronated feet may benet most from shoes
with motion control.
Table 3 Results of the unadjusted and adjusted Cox regression models for the variables tested
Indicator
Unit/qualifier
Unadjusted model Adjusted model
HR 95% CI p Value HR 95% CI
Main exposure of interest
Shoe version Standard shoes is ref 0.59* 0.39 to 0.91 0.0160.55* 0.36 to 0.85
Participantscharacteristics
Age Years 0.99 0.97 to 1.01 0.1500.99 0.97 to 1.02
Sex Male is ref 1.02 0.67 to 1.54 0.944
BMI 1 kg/m
2
increase 1.07* 1.01 to 1.15 0.0341.05 0.98 to 1.12
Previous injury No (previous injury) is ref 2.77* 1.82 to 4.21 <0.0012.70* 1.77 to 4.11
Running experience Years 0.99 0.97 to 1.02 0.527
Regularity (last 12 months) Months 0.90* 0.82 to 0.99 0.0280.91 0.83 to 1.01
Foot morphology Neutral is ref
Supinated (and highly) 1.27 0.72 to 2.24 0.4051.42 0.80 to 2.54
Pronated (and highly) 1.34 0.84 to 2.15 0.2251.43 0.88 to 2.30
Sport participation pattern
Other sports frequency Sessions/week 1.04 0.91 to 1.18 0.617
Running frequency Sessions/week 0.78 0.61 to 1.01 0.0570.82 0.62 to 1.08
Mean session duration min 1.00 0.99 to 1.01 0.974
Mean session distance km 0.90* 0.83 to 0.98 0.0140.93 0.86 to 1.02
Mean session intensity au 0.91 0.73 to 1.14 0.424
*Significant results.
Variables with p value <0.200 or used for the stratified randomisation were included in the adjusted model; total volume of exposure: 12 094 h; au, arbitrary unit; BMI, body mass
index.
Years of regular practice of running.
Table 4 Stratified analysis of the effect of shoe version according to foot morphology (n=372)
Supinated feet Neutral feet Pronated feet
Injured/non-injured
HR (95% CI)
p value
Injured/non-injured
HR (95% CI)
p value
Injured/non-injured
HR (95% CI)
p value
Standard shoes 11/19
1.49 (0.74 to 2.98)
0.263
30/78
1
19/28
1.80* (1.01 to 3.22)
0.048
Motion control shoes 5/25
0.76 (0.29 to 1.97)
0.574
21/89
0.79 (0.45 to 1.38)
0.398
7/40
0.64 (0.28 to 1.45)
0.280
HR (95%CI); p value for shoe version within strata
of foot morphology (standard shoes is ref)
0.59 (0.20 to 1.73)
0.335
0.78 (0.44 to 1.37)
0.382
0.34* (0.13 to 0.84)
0.020
*Significant results; the reference was the group of runners with neutral feet, using neutral shoes.
6 Malisoux L, et al.Br J Sports Med 2016;0:17. doi:10.1136/bjsports-2015-095031
Original article
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How might it impact on clinical practice in the future?
With cushioned running shoes, some motion control may be
necessary to limit injury risk in recreational runners.
Recreational runners with pronated feet using neutral shoes
may be at an increased risk of injury.
Runners with pronated feet may be advised to try motion
control shoes for running.
Acknowledgements The authors would like to thank Dr Stephen Senn for
preparing the randomisation, and Mr Daniel Karels and Mrs Romy Primc for their
precious assistance with data collection.
Contributors LM, NC, ND, NG, AU and DT contributed to the study conception
and study design; LM was responsible for the acquisition and analysis of the data.
NC was responsible for shoe testing. LM and DT were responsible for data
interpretation and manuscript drafting. LM, NC, ND, NG, AU and DT contributed to
critical manuscript revision and approval. LM and DT were responsible for the overall
content.
Funding This study was co-funded by Decathlon, Movement Sciences Department,
Villeneuve dAscq, France.
Competing interests A research partnership agreement was signed between
Decathlon and the LIH. ND, NC and NG are employed at Decathlon Group.
Patient consent Obtained.
Ethics approval National Ethics Committee for Research (CNER; ref 201211/04).
Provenance and peer review Not commissioned; externally peer reviewed.
Open Access This is an Open Access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-commercially,
and license their derivative works on different terms, provided the original work is
properly cited and the use is non-commercial. See: http://creativecommons.org/
licenses/by-nc/4.0/
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Malisoux L, et al.Br J Sports Med 2016;0:17. doi:10.1136/bjsports-2015-095031 7
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blinding
controlled trial with participant and assessor
motion control shoes: a randomised
Injury risk in runners using standard or
Axel Urhausen and Daniel Theisen
Laurent Malisoux, Nicolas Chambon, Nicolas Delattre, Nils Gueguen,
published online January 8, 2016Br J Sports Med
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Supplementary resource (1)

... In the lower limbs, the knee and the foot are the most commonly injured locations due to intrinsic factors such as biomechanical abnormalities and muscle functionality [4], or extrinsic factors such as poor running technique [5] or unsuitable running shoes [6]. Overall, the biomechanical effects associated with foot-strike pattern, such as anatomic alignment of lower limb structures [7], stride length or foot pronation, and the greater vertical ground reaction force load rate are thought to be important issues related to several overuse injuries [8,9]. ...
... The relationship between load rates and running injuries has led to the development of two main strategies to reduce their incidence: gait retraining to lessen running impact [14] and modifying foot strike pattern from rear foot strikes to non-rear foot strikes [15] by using specific footwear in order to change foot-strike pattern [6]. In this sense, previous research has reported that 95% of runners are rear foot strikers (RFS) [16]. ...
... Despite several decades of running shoe development aimed at reducing injuries, the incidence of overuse injuries has remained relatively unchanged [58]. In recent years, clinicians', podiatrists', and researchers' efforts have been focused on designing running footwear adaptations aimed at reducing the incidence of overload injuries in runners [6], improving their sport performance [59,60], and analysing foot movement and posture [61]. To date, a 12-week gait retraining programme using floating heel running footwear has obtained promising results. ...
Article
Full-text available
Foot-strike and the associated load rate are factors related to overuse injuries in runners. The purpose of this study was to analyse structural and functional changes in runners using floating heel running shoes, compared with runners using conventional footwear. A randomised control trial was conducted. Twenty runners with overuse injuries were followed over a 12-week gait retraining programme using floating heel running shoes or their conventional footwear. Pain was measured with pressure pain thresholds (PPTs), structural changes were measured with ultrasonography, and severity and impact of injury was scored on the Oslo Sports Trauma Research Centre Overuse Injury Questionnaire (OSTRC-O). Statistical differences were found between groups after the intervention (p < 0.001), with a medium size effect SE = 0.8, and the floating heel running shoes group reached higher PPTs values. Participants using floating heel running shoes showed higher OSTRC-O scores than those using their conventional footwear (p < 0.05), with higher scores after the intervention (p < 0.05). A 12-week gait retraining programme using floating heel running shoes had positive effects on the injury recovery process when compared to the use of conventional footwear, with significant differences in terms of pain and impact on sports activity.
... 21,24,25 Based on this scientific evidence, many studies have focused on controlling these risk factors (plantar arch index [AI] and foot pronation posture) for injury in runners, especially with gait training. Recent studies 14,[26][27][28][29][30] have suggested that appropriate gait training can successfully change the biomechanics of recreational runners, with or without the effects of shoes, 14,29,30 in a short period of time (5-8 training sessions). [26][27][28] One study showed that a 2-week gait retraining program that used real-time visual feedback was effective in lowering impact plantar loading in recreational runners, with a 62% reduction in injuries after 2 weeks of intervention. ...
... 21,24,25 Based on this scientific evidence, many studies have focused on controlling these risk factors (plantar arch index [AI] and foot pronation posture) for injury in runners, especially with gait training. Recent studies 14,[26][27][28][29][30] have suggested that appropriate gait training can successfully change the biomechanics of recreational runners, with or without the effects of shoes, 14,29,30 in a short period of time (5-8 training sessions). [26][27][28] One study showed that a 2-week gait retraining program that used real-time visual feedback was effective in lowering impact plantar loading in recreational runners, with a 62% reduction in injuries after 2 weeks of intervention. ...
... 28 Other biofeedback gait retraining programs using real-time visual feedback to control plantar load rate have been tested and shown to cause a favorable running gait pattern transition. 9,30 Gait retraining programs that include visual feedback are promising tools for improving foot support by reducing plantar loading and RRIs. 15,20,[26][27][28]31 They are particularly attractive due to their convenience, availability, interactivity, and relatively low cost to develop and implement. ...
Article
Context: Running is a popular sport globally. Previous studies have used a gait retraining program to successfully lower impact loading, which has been associated with lower injury rates in recreational runners. However, there is an absence of studies on the effect of this training program on the plantar pressure distribution pattern during running. Objective: To investigate the short-term effect of a gait retraining strategy that uses visual biofeedback on the plantar pressure distribution pattern and foot posture in recreational runners. Design: Randomized controlled trial. Setting: Biomechanics laboratory. Participants: Twenty-four recreational runners were evaluated (n = 12 gait retraining group and n = 12 control group). Intervention: Those in the gait retraining group underwent a 2-week program (4 sessions/wk, 30 min/session, and 8 sessions). The participants in the control group were also invited to the laboratory (8 times in 2 wk), but no feedback on their running biomechanics was provided. Main outcome measures: The primary outcome measures were plantar pressure distribution and plantar arch index using a pressure platform. The secondary outcome measure was the foot posture index. Results: The gait retraining program with visual biofeedback was effective in reducing medial and lateral rearfoot plantar pressure after intervention and when compared with the control group. In the static condition, the pressure peak and maximum force on the forefoot and midfoot were reduced, and arch index was increased after intervention. After static training intervention, the foot posture index showed a decrease in the foot pronation. Conclusions: A 2-week gait retraining program with visual biofeedback was effective in lowering rearfoot plantar pressure, favoring better support of the arch index in recreational runners. In addition, static training was effective in reducing foot pronation. Most importantly, these observations will help healthcare professionals understand the importance of a gait retraining program with visual biofeedback to improve plantar loading and pronation during rehabilitation.
... Therein, high-support footwear possesses a medial post (i.e., midsole that is stiffer medially compared to laterally), increased longitudinal bending stiffness, and midfoot rotational stability to minimize excessive foot pronation during activity, whereas low-support footwear does not [16]. Although motion-control shoes have been shown to reduce risk of pronation-related injuries [17], no footwear features have been associated with altered risk of ACL injury. However, modifying medial and lateral support in footwear does affect frontal and transverse-plane knee loads [18][19][20], which may affect ACL loads [21]. ...
Article
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Rates of anterior cruciate ligament (ACL) rupture in young people have increased markedly over the past two decades, with females experiencing greater growth in their risk compared to males. In this study, we determined the effects of low- and high-support athletic footwear on ACL loads during a standardized drop–land–lateral jump in 23 late-/post-pubertal females. Each participant performed the task unshod, wearing low- (Zaraca, ASICS) or high- (Kayano, ASICS) support shoes (in random order), and three-dimensional body motions, ground-reaction forces, and surface electromyograms were synchronously acquired. These data were then used in a validated computational model of ACL loading. One-dimensional statistical parametric mapping paired t-tests were used to compare ACL loads between footwear conditions during the stance phase of the task. Participants generated lower ACL forces during push-off when shod (Kayano: 624 N at 71–84% of stance; Zaraca: 616 N at 68–86% of stance) compared to barefoot (770 N and 740 N, respectively). No significant differences in ACL force were observed between the task performed wearing low- compared to high-support shoes. Compared to barefoot, both shoe types significantly lowered push-off phase peak ACL forces, potentially lowering risk of ACL injury during performance of similar tasks in sport and recreation.
... Likewise, Nielsen et al. (2014) did not find significant differences in injury risk among 927 novice runners with varying arch types who trained in neutral shoes. Malisoux et al. (2016) found contrasting results when randomly assigning either a neutral or motion control shoe to a group of 372 recreational runners. During 6-months of observation, sixty (of 185) runners in the neutral shoe group reported an injury compared to 33 (of 187) in the motion control group. ...
Article
Full-text available
Many runners seek health professional advice regarding footwear recommendations to reduce injury risk. Unfortunately, many clinicians, as well as runners, have ideas about how to select running footwear that are not scientifically supported. This is likely because much of the research on running footwear has not been highly accessible outside of the technical footwear research circle. Therefore, the purpose of this narrative review is to update clinical readers on the state of the science for assessing runners and recommending running footwear that facilitate the goals of the runner. We begin with a review of basic footwear construction and the features thought to influence biomechanics relevant to the running medicine practitioner. Subsequently, we review the four main paradigms that have driven footwear design and recommendation with respect to injury risk reduction: Pronation Control, Impact Force Modification, Habitual Joint (Motion) Path, and Comfort Filter. We find that evidence in support of any paradigm is generally limited. In the absence of a clearly supported paradigm, we propose that in general clinicians should recommend footwear that is lightweight, comfortable, and has minimal pronation control technology. We further encourage clinicians to arm themselves with the basic understanding of the known effects of specific footwear features on biomechanics in order to better recommend footwear on a patient-by-patient basis.
... These studies generally involve much greater numbers of participants (at least several hundred) and follow up over several months in an observational study 14,30 or a randomized trial. 15,31,32 The latter design has the advantage of randomization, which allows for an equal distribution among study groups of all other factors that may influence injury risk. Observational cohort studies and randomized trials make it possible to study the long-term effects of personal characteristics, training behavior, or a given shoe type on running injury. ...
... However, since the current prevention tutorials for potential motion damage are not published, they are only provided for professional sports personnel, so comprehensive data information cannot be collected. erefore, it is impossible to make accurate judgments, which hinders the preventive measures of potential injuries of athletes and also greatly wastes time and resources [5]. ...
Article
Full-text available
Objective: This work aimed to study the posture judgment method of 3D image analysis of potential motion damage. Methods: The motion damage collection was implemented by the 3D image analysis method, and 3D image data were adopted to identify the motion damage data. Moreover, 3D image acquisition technology was adopted to analyze the model of potential motion damage and analyze the simulation judgment result of potential motion damage. Specifically, it included simulation parameters, motion damage posture collection effect, damage detection speed at the collection point, damage accuracy, and damage degree. Results: (1) The analysis of the damage monitoring speed at multiple collection points of the athletes in the sports environment confirmed that the range of changes in different time periods was different, and the changes showed a fast to slow to fast trend. (2) The 3D image analysis had high accuracy in analyzing the posture of potential motion damage, which rationalized the evolution of injuries. (3) The degree of motion damage under a 3D image changed from rising to gradual, which was in line with the theoretical results (all p < 0.05). Conclusion: 3D image analysis can collect a high degree of small-sample-size data, then perform specific analysis, judgment, and summary, and finally, obtain objective and reasonable data. It greatly reduced the risk of potential motion damage for athletes and also improved the efficiency of injury recognition. Moreover, it reduced the chances of blind prevention and error prevention by athletes, thereby avoiding waste of resources. The simulation test confirmed the advantages of 3D image data collection in the sports environment, and it was solved that the current athletes cannot accurately and timely judge the potential motion damage. It also met the instability needs of the movement personnel of the acquisition system in the changing sports environment and provided a reliable guarantee for the safety and health of the sport personnel.
... 30 A randomized controlled trial showed that, in runners who overpronate, motion-control shoes reduced their risk of injury. 31 However, another study assessed whether shoes that had been "prescribed" based on foot morphology and stride reduced the risk of injury (compared to neutral, cushioned shoes) and found no change in the incidence of soft-tissue injury. 32 Given no strong evidence to suggest otherwise, runners can be advised to buy shoes based on comfort rather than on foot morphology or running stride. ...
Article
Assess risk factors, then work to address modifiable ones, such as wearing the right running shoes and building up slowly. Don't let overweight or OA dampen enthusiasm.
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Running-related injuries remain problematic among recreational runners. We evaluated the association between having sustained a recent running-related injury and speed, and the strike index (a measure of footstrike pattern, SI) and spatiotemporal parameters of running. Forty-four previously injured and 46 previously uninjured runners underwent treadmill running at 80%, 90%, 100%, 110%, and 120% of their preferred running speed. Participants wore a pressure insole device to measure SI, temporal parameters, and stride length (Slength) and stride frequency (Sfrequency) over 2-min intervals. Coefficient of variation and detrended fluctuation analysis provided information on stride-to-stride variability and correlative patterns. Linear mixed models were used to compare differences between groups and changes with speed. Previously injured runners displayed significantly higher stride-to-stride correlations of SI than controls (P = 0.046). As speed increased, SI, contact time (Tcontact), stride time (Tstride), and duty factor (DF) decreased (P < 0.001), whereas flight time (Tflight), Slength, and Sfrequency increased (P < 0.001). Stride-to-stride variability decreased significantly for SI, Tcontact, Tflight, and DF (P ≤ 0.005), as did correlative patterns for Tcontact, Tstride, DF, Slength, and Sfrequency (P ≤ 0.044). Previous running-related injury was associated with less stride-to-stride randomness of footstrike pattern. Overall, runners became more pronounced rearfoot strikers as running speed increased.
Article
The purpose of this study was to investigate the influence of midsole hardness on both impact forces and rearfoot motion. Seven trained male long-distance runners were assessed with a Kistler force plate and with high-speed video, while running at 4.5 ± 0.1 m·s-1 with soft and hard shoe soles (EVA; soft shore Asker C40; hard shore Asker C65). The results showed smaller initial vertical impact peaks, occurring with a higher loading rate, and a significantly larger and faster initial eversion when subjects ran with hard shoes. Support is given to the concept that a more pronounced initial eversion offers an additional deceleration mechanism (Stacoff, Denoth, Kaelin, and Stuessi, 1988) also increasing the eccentric loading of the inverting muscles. On the other hand, during midstance soft shoe soles were found to produce a larger maximum eversion and pronation, also imposing an increased load on the same muscles. So, a good running shoe should be focused on a balance between reducing impact forces and reducing overpronation.
Article
In the past 100 years, running shoes experienced dramatic changes. The question then arises whether or not running shoes (or sport shoes in general) influence the frequency of running injuries at all. This paper addresses five aspects related to running injuries and shoe selection, including (1) the changes in running injuries over the past 40 years, (2) the relationship between sport shoes, sport inserts and running injuries, (3) previously researched mechanisms of injury related to footwear and two new paradigms for injury prevention including (4) the 'preferred movement path' and (5) the 'comfort filter'. Specifically, the data regarding the relationship between impact characteristics and ankle pronation to the risk of developing a running-related injury is reviewed. Based on the lack of conclusive evidence for these two variables, which were once thought to be the prime predictors of running injuries, two new paradigms are suggested to elucidate the association between footwear and injury. These two paradigms, 'the preferred movement path' and 'the comfort filter', suggest that a runner intuitively selects a comfortable product using their own comfort filter that allows them to remain in the preferred movement path. This may automatically reduce the injury risk and may explain why there does not seem to be a secular trend in running injury rates. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Article
Variations in definitions and methodologies have created differences in the results and conclusions obtained from studies of football (soccer) injuries, making interstudy comparisons difficult. Therefore an Injury Consensus Group was established under the auspices of Fédération Internationale de Football Association Medical Assessment and Research Centre. A nominal group consensus model approach was used. A working document on definitions, methodology, and implementation was discussed by the group. Iterative draft statements were prepared and circulated to members of the group for comment before the final consensus statement was produced. Definitions of injury, recurrent injury, severity, and training and match exposures in football together with criteria for classifying injuries in terms of location, type, diagnosis, and causation are proposed. Proforma for recording players’ baseline information, injuries, and training and match exposures are presented. Recommendations are made on how the incidence of match and training injuries should be reported and a checklist of issues and information that should be included in published reports of studies of football injuries is presented.
Article
For many years, U.S. Army soldiers performed physical training (PT) in a modified duty uniform and combat boots. The belief that PT in combat boots was associated with injuries lead to the introduction of running shoes for PT in 1982. A historical comparison was conducted examining injuries before and after the change to running shoes in Basic Combat Training (BCT). Searches in literature databases and other sources identified 16 studies with quantitative data on injury incidence during 8-week BCT cycles. Employing studies with similar injury definitions (n = 12), injury incidence was compared in the boot and running shoe periods using meta-analyses, χ(2) statistics, and risk ratios (RRs) with 95% confidence intervals (95% CIs). The boot and shoe periods demonstrated little difference in overall injury incidence (men: RR[boot/shoes] = 1.04, 95% CI = 0.91-1.18, p = 0.50; women: RR = 0.94, 95% CI = 0.85-1.05, p = 0.27) or in lower extremity injury incidence (men: RR[boot/shoes] = 0.91, 95% CI = 0.64-1.30, p = 0.66; women: RR = 1.06, 95% CI = 0.89-1.27, p = 0.51). These analyses provided little support for a reduction in injury risk after the switch from boots to running shoes for PT in BCT. A large randomized, prospective cohort study should be conducted to determine if injury rates are different when PT is conducted in running shoes versus boots. Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.
Article
Study design: Secondary analysis of 3 randomized controlled trials. Objective Analysis of studies that examined whether prescribing running shoes on the basis of foot arch height influenced injury risk during military basic training. Background: Prior to 2007, running magazines and running-shoe companies suggested that imprints of the bottom of the feet (plantar shape) could be used as an indication of foot arch height and that this could be used to select individually appropriate types of running shoes. Methods: Similar studies were conducted in US Army (2168 men, 951 women), Air Force (1955 men, 718 women), and Marine Corps (840 men, 571 women) basic training. After foot examinations, recruits were randomized to either an experimental or a control group. Recruits in the experimental group selected or were assigned motion-control, stability, or cushioned shoes to match their plantar shape, which represented a low, medium, or high foot arch, respectively. The control group received a stability shoe regardless of plantar shape. Injuries during basic training were assessed from outpatient medical records. Results: Meta-analyses that pooled results of the 3 investigations showed little difference between the experimental and control groups in the injury rate (injuries per 1000 person-days) for either men (summary rate ratio = 0.97; 95% confidence interval [CI]: 0.88, 1.06) or women (summary rate ratio = 0.97; 95% CI: 0.85, 1.08). When injury rates for specific types of running shoes were compared, there were no differences. Conclusion: Selecting running shoes based on arch height had little influence on injury risk in military basic training. Level of evidence: Prevention, level 1b.