Strengthening the Feet Will Not Correct Biomechanical Problems: Pribut

12/14/2009      Ray McClanahan, DPM


Dr. Pribut's published opinion regarding feet strengthening and barefoot activity contains many assumptions that are addressed in a recent sports medicine article on running shoes.

Is your prescription of distance running shoes evidence-based? C E Richards, P J Magin, R Callister. Br. J. Sports Med. 2009;43;159-162.

The assumptions, which seem to have become standard of care in sports podiatry, which have yet to be proven, and may be incorrect, are:

Over-pronation and faulty biomechanics are the causes of running injuries.

Over-pronation is a bone structure problem, un- affected by strengthening, and somehow corrected by orthotics and motion controlling footwear. Barefoot activity is only for the elite, or as Dr. Pribut stated, for those whose arches are not low.

Athletic footwear is healthy for runners, and some runners need shoes to guide them, and correct their pronation.

There is no evidence for any of these assertions.

Faulty gait patterns, overpronation, foot weakness, and chronic injuries in runners are caused by footwear, not corrected by footwear.

There is much evidence supporting this, both in the medical literature, and in physiologic tests that each of us can perform in our offices to show the proof.

The most compelling proof that I demonstrate to each of my runners, and encourage you to use, to prove that pronation is not a bone-structure problem, is a test that I developed, and wish to share.

Have your patient stand in front of you barefoot, and maximally pronate one of their arches. Have the patient look at the amount of pronation, and you the clinician, can see how far the navicular drops. Then, move your patients foot into supination, while simultaneously pulling their hallux away from the second toe, and move the hallux towards the midline. Then have your patient slowly pronate, while fully weight bearing.

EVERYONE, except for the very hypermobile, will pronate less, and will feel the effect of their flexor hallucis longus, inhibiting the drop of the sustentaculum tali.

None of your current running patients, are able to accomplish this, due to the fact that no running shoe allows the hallux to be adducted from the midline of the foot.

The tapered toebox on all running shoes, is what pushes the hallux towards the second toe, and unlocks the subtalar joint, encouraging pronation. Shoes are the cause.

Our currently-accepted biomechanical theory of subtalar joint pronation, causing hallux abducto valgus, is completely backwards. This is why orthotics have never cured or slowed the progression of a bunion, when worn in footwear with tapered toeboxes, which all running shoes currently have.

Abducting the hallux is what causes bunions and pronation, not the other way around. Hallux abduction is caused by shoes.

My patients and I are proving this daily with a silicone toe spreading device, called Correct Toes, which I invented, and we use in racing flats, and Crocs.

Many of our patients are having a positive running experience with Vibram 5 Fingers, which is like a toe sock, with rubber on the bottom.

I have learned that runner's do not need to actually be barefoot, to reap the benefits of barefoot running. There are a very few shoes that can be modified to create a barefoot presentation, inside of the shoe. This presentation has the heel level with all of the phalanges, toes spread, and allows full foot flexion throughout the sole.

Many companies are coming out with minimalist footwear that promises to deliver the health benefits of barefooting. Sadly, most of these shoes that I have reviewed do not position the feet of runners remotely close to how they would be, if they were actually barefoot.

Let's not stamp our seal of approval on these shoes and let's not be surprised when runners fail to achieve the nearly injury - less state of the unshod running foot.

Let's also ask ourselves, after reading the article above, if there is something that all of us who treat runners can learn, to help our runners not get hurt.

Ray McClanahan, DPM, Portland, OR, footdr@nwfootankle.com