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RE: Do Runners Need Orthotics? (Kevin Kirby, DPM)

From: Robert Bijak, DPM

In response to Dr. Kirby's query, I feel running shoe selection is more important than custom orthotics. Most shoes have intrinsic built-in characteristics for runners and their environments. I have found the orthotic that comes with the shoe or an OTC has been satisfactory in the majority of the cases. Although a small percentage may benefit from a so-called "custom" support, I believe the primary motive for prescribing is financial. In all honesty, if you took the profit motive away from "custom orthtotics", many podiatrists wouldn't go through all the trouble attendant with them.

Robert Bijak, DPM, Clarence Center, NY

Other messages in this thread:



RE: Cross-Country Runner Using Spikes (Martin E. Karns, DPM)

From: Philip McKinney, DPM

Decades ago, running cross-country in high school, all we had to run with on a grass course were spikes. Back then, the only racing flats were road racing shoes; cross-country racing flats had not yet been developed. Near the end of my high school career, the first of the cross-country racing flats was being developed, and they were nothing more than track spikes with the waffle sole from Blue Ribbon Sports (which became Nike) glued to the rear of the spike. Through college, if the surface were dry and firm, we wore cross-country racing flats. If the course were wet and sloppy, spikes.

I suspect your question has to do with the prospect of injury for a high school runner to be running on spikes over an uneven surface. I think that the runner falling because of poor footing from a wet and muddy surface and being hurt would be more likely than any injury from running 5K on a cross-country surface in a light-weight spike. Personally, money allowing, I would have a pair of spikes and a pair of cross-country racing flats. If he is able to afford only one pair, then I recommend something like Asics HyperXCS; Nike Zoom Waffle; Saucony Shay XCS or Adidas XC 3.


Philip McKinney, DPM, Eugene, OR,



RE: Cross-Country Runner Using Spikes (Martin E. Karns, DPM)

From: Keith L. Gurnick, DPM

The use of spikes for high school cross-country running is unnecessary and potentially very hazardous, and in many regions, disallowed for racing. Acute injuries can include laceration to one's self and/or others from the actual sharp spikes. Also, if the running surface is grassy, uneven, or hilly, the spikes can hang up or get caught in tree roots and other surface objects, causing trip and fall accidents. 

Spike shoes in track and field (which is not the same as cross-country running) are designed to be racing flats (very thin, light-weight, and non-supportive). They are designed for racing or for training for sprint racing on flat even surfaces, which in the past, included dirt tracks, where the traction was not great. They still are used on modern synthetic rubber tracks seen in many high schools and colleges around the world today. Also, modified spike shoes are still used on artificial surfaces in many field events to increase foot traction, including high jump, pole vault, triple jump, javelin, etc. Spikes can be very dangerous because they are sharp.

Keith L. Gurnick, DPM, Los Angeles, CA,



RE: Source For Football Cleat (Howard J. Bonenberger, DPM)

From: Robert M. Conenello, DPM

Most football cleats are built on a straight last. I suggest that any athlete should try on the shoe with the appropriate football socks. Toebox room is relative to the individual, and thus comfort is subjective.

Robert M. Conenello, DPM, Orangeburg, NY,



RE: Biomechanics of Barefoot Running

From: Jefferson J. Mennuti, DPM

So, it seems we need to tally the pros and cons of minimalist vs. conventional shoes.

Pros of minimalist shoes: zero drop shoe, which allows for a midfoot/forefoot gait. Better protection from surface debris than barefoot running.

Cons of minimalist shoes: no support. You are forced to run with a mid/fore foot gait, therefore it's not good for slow paced running, or walking.

Pros of conventional running shoes: cushioning, and support. Allows for runners to run longer before fatigue.

Cons of conventional running shoes: elevated heel. Contraction of the Achilles. Basically forces heel strike running.

I think if people want to run the way they want to run, we should be flexible enough to recommend the appropriate measures.  

Jefferson J. Mennuti, DPM, Orange City, FL,



RE: Biomechanics of Barefoot Running (Jefferson J. Mennuti, DPM)

From: Brad Makimaa, DPM

I would like to clarify some of the ideas of this principle. I would also like to call for someone in one of our "podiatric educational institutions" to create a revolutionary road map for the prescription of the proper shoes based on speed and patient makeup. We are the shoe gurus and there should be no second place on this issue. If you want to run in any style, you must see a podiatrist first; just like a school physical for sports is mandatory.

This is not a black and white issue. Everyone will or can run on the forefoot. Just speed up. Therefore, simply asking the patient how fast they run will...

Editor's note: Dr. Makimaa's extended-length letter can be read here.



RE: Biomechanics of Barefoot Running (Dennis Shavelson, DPM)

From: Jefferson J. Mennuti, DPM

I appreciate Dr. Shavelson's response. I have gotten some rather unsavory personal emails from those that have either parted ways with or never met their acumen. One such individual wanted me to imagine running in a forefoot contact way and then imagine my Achilles as a bungee cord being rather slack than in a very strong moment of contraction. I think this is rather incorrect. I believe the posterior groups work in conjunction with the anterior groups, some in eccentric contraction, some in concentric contraction, depending on the moment.

I am interested in the concept of the PL taking less load with the forefoot contact (FFC) vs. heel contact (HC). In addition, since FFC requires a higher cadence, the number of contractions to the PL encounters would perhaps quadruple.

Reviewing the literature, the two articles confirmed that FFC runners have faster times, yet fatigue and revert to HC. The one article directly referred to was based on "recreational" runners. Hasagawa attempted the "elite." Moving forward, three EBM studies so far in the literature are begging further study.

Jefferson J. Mennuti, DPM, Orange City, FL,



RE: Biomechanics of Barefoot Running

From: Jefferson J. Mennuti, DPM

I have been thumbing through some of the recent literature about the above subject. I think the reality of this debate is not, in fact, barefoot running per se. I believe the real issue is biomechanics; specifically forefoot running vs. heel striking. So, I would like to shift this thought process from "barefoot running" to "forefoot vs. heel strike running."

In my vast history with running (5 weeks), ...

Editor's note: Dr. Mennuti's extended-length letter can be read here.



RE: Do Runners Need Orthotics? (Robert Bijak, DPM)

From: Gino Scartozzi, DPM

The question as to whether custom orthotics are necessary to treat foot problems is based upon the activity level of the patient and whether activity levels predispose the patient to larger stresses than that of a more sedentary patient. The decision to proceed with a custom orthotic is also dependent as to the amount of symptomatic relief they obtain with other conservative management treatments used.

Certainly, patients who are sedentary and/or respond quickly from other conversative treatments may benefit from, as Dr. Bijak states, an over-the-counter insole since their activity stresses are not the same of those of athletes. However, I believe that Dr. Bijak may be short-sighted when he states there is a "profit motive" with most practitioners using custom orthotics and their "inconveniences."

Gino Scartozzi, DPM, New Hyde Park, NY,



RE: Do Runners Need Orthotics? (Robert Bijak, DPM)

From: H. David Gottlieb, DPM

Dr. Bijak, why the use of quotes around custom orthoics in your recent post regarding runners? An insert is either custom or it's not. If the prescription for the orthotic is marked "Post To Cast", then I agree that it's not really a functional orthotic under anyone's methodology.

As to your statement, "if you took the profit motive away from 'custom orthotics', many podiatrists wouldn't go through all the trouble attendant with them." I find that there is very little trouble attendant with prescribing and dispensing orthotics because they work well for the majority of my patients. And as a VA employee, I have no profit motive. My incentive is to fix my patients problems so I can see other patients. I evaluate my patients well, write a customized prescription for each, and explain how they should use them. Some orthotics may need an adjustment, but the overwhelming number do very well. And because they work for me, I use them a lot.

Other podiatrists here don't get good results with orthotics and therefore don't believe in them. They don't use orthotics or they have me do them. I tell our residents and visiting students that if orthotics take up too much time, they are not doing them right. They need to figure out how to do orthotics correctly or don't do them at all.

H. David Gottlieb, DPM, Baltimore, MD,



RE: Do Runners Need Orthotics? (Kevin Kirby, DPM)

From: Michael B. DeBrule, DPM

I have no problem with Dr. Campitelli advocating for minimalist shoes if that works for his patients, and I won’t speculate on his personal financial motivations with Vibram. I firmly agree with Dr. Kirby that there are a lot of studies justifying the use of orthotics for runners. I would like to see Dr. Kirby, Dr. Campitelli, and other leaders of our profession work together designing some studies looking at injury rates for runners who are unshod, wearing minimalist shoes, wearing running shoes, and wearing foot orthotics.

Personally, I recommend running barefoot or in minimalist shoes for patients who fail to improve with changes in shoes and orthotic therapy, which is not often. It takes at least several months to transition to these and they may introduce new discouraging injuries (Achilles tendonitis, stress fracture, top of the foot pain). Also, before your patients spend a lot of money on Vibrams, Nike Free, etc., consider Huaraches from They are about 1/3 of the price and last ten times longer. The last issue of Runner’s World forgot to mention invisible shoes in their shoe guide as a low-cost alternative.

Michael B. DeBrule, DPM,  Marshall, MN,



RE: Do Runners Need Orthotics? (Robert Bijak, DPM)

From: Robert Scott Steinberg, DPM

I look at running shoe selection from two points: 1) If the runner over-pronates, I recommend a shoe that does not add to that pronation by being too soft and flexible. 2) If the runner is going to wear a prescription functional orthotic, I recommend a shoe that is stable side-to-side, so the orthotic can maintain a STJ neutral position. A cushioned/"neutral"/minimalist shoe just can't cut it, for these runners.

My patients get a list of running and walking shoes in both the stability and motion control categories, with my 1st, 2nd, & 3rd suggestions highlighted. The best shoe for the foot type may be all my patient needs, along with things like stretching, etc. And, if their plantar fasciitis, ankle or knee pain do not improve enough, then I look to control the abnormal biomechanics via an orthotic. Remember, an excessively pronating foot is not controlled by the sock liner that comes with the shoe.

Robert Scott Steinberg, DPM, Schaumburg, IL,



RE:  Do Runners Need Orthotics? (Kevin Kirby, DPM)

From: Robert Scott Steinberg, DPM

I read Dr. Campitelli's comments on Podiatry Today's forum. I had to read it three times to believe that a podiatrist could be so clueless about orthotics and shoes. Dr. Kirby has given me the answer. Dr. Campitelli gives all the appearances of having been "bought" by Vibram 5-Fingers. He is using unscientific urban rumor to support his position. It is a clear violation of his oath and the code of ethics of the APMA and his state society. What will be so damaging is that he will be quoted by this tiny faction of the in-need-of-an-ego-boost subset of runners. On a positive note, it's good for my practice.

Robert Scott Steinberg, DPM, Schaumburg, IL,



RE: Keeping Toes Warm During Antarctica Marathon (Ayne Furman, DPM)

From: Paul Busman, DPM, RN

I suggest that your patient consider a psych evaluation rather than worry about what socks to wear for the Antarctic Marathon. We're talking about the Ant-freakin'-arctic here! Temperatures, according to the marathon's website, of -21C, plus wind. The cost for this little jaunt in the park (a 5 day package) is 9,900 Euro from Chile (so add airfare to Chile too). As of this morning, that's $12,805 USD. I know, I know, it's a personal challenge, yadda yadda. I still think it's kind of irrational to spend that kind of fortune to run a race that stands a good chance of your leaving frozen bits of yourself behind.

Note: If the marathon isn't insane enough, they run an ultra-marathon in the Antarctic too! 

Paul Busman, DPM, RN, Clifton Park, NY,



RE: Keeping Toes Warm During Antarctica Marathon (Ayne Furman, DPM)

From: Brian Kiel, DPM, Robert Scott Steinberg, DPM

I  recommend a fleece and neoprene sock. Gator makes one (Gator fleece-lined neoprene sock). It is available at I am sure other sites have them as well.


Brian Kiel, DPM, Memphis, TN,

Keeping feet warm and dry requires a whole body approach. Start with a tights-type base layer, top and bottom (against the skin). Your best bet is to go to a winter ski shop. Base layers must wick moisture and allow it to evaporate through additional layers that do not trap moisture. Nothing, and I mean nothing, should have even a single thread of cotton. The number of layers, or the loft weight of additional layer, will depend on race day conditions. Windproof and breathable outer layers are a must. Patagonia makes some of the finest cold weather clothes. Their layering systems are very well proven.

Head protection is very important. If you get too hot, head coverings are the easiest to...

Editor's note: Dr. Steinberg's extended-length letter can be read here.



RE: Foot Strike Patterns in Recreational Runners

From: Kevin A. Kirby, DPM

There is currently considerable debate on proper foot strike technique for runners within the sports medicine and running communities. A number of alternative "running styles", including Chi Running and Pose Running, are being preached to runners as better running styles where the runner is taught to not heel strike during running, but rather is taught to contact the ground on the midfoot and forefoot. These new "fads" of running have now reached the level that many runners who normally heel strike have been told by a friend or coach to modify their running style to a midfoot/forefoot striking pattern which may lead to new running injuries. As a result of seeing this trend of new running injuries grow over the past few years in my practice, I now routinely ask my runner-patients on their initial examination if they tried to change their running form sometime before their running injury started.


In this regard, a new paper has just been added to the literature which demonstrates that out of 936 recreational and sub-elite runners, 88.9% of runners at the 10K mark of a half-marathon/marathon road race were heel strikers, 3.4% were midfoot strikers, and only 1.8% were forefoot strikers (Larson P, Higgins E, et al.: Foot strike patterns of recreational and sub-elite runners in a long-distance road race. 2011 Nov 18, Epub ahead of print.) This is only the third scientific study ever published that has classified the percentages of rearfoot, midfoot, and forefoot strikers during long distance road races.


Kevin A. Kirby, DPM, Sacramento, CA,

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