Injury Incidence Between Barefoot and Shod Runners

INJURY INCIDENCE BETWEEN BAREFOOT AND SHOD
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A Correlational Analysis of Reported Injury Incidence between
Barefoot and Shod Runners
CHAD WOODARD
A Dissertation
Presented to the Dissertation Committee of the
College of Health Sciences of Trident University International
in Partial Fulfillment of the Requirements for the Degree of
Doctor of Philosophy in Health Science
(Defended June 20, 2018)
Approved by:
Office of Academic Affairs
Date June 20, 2018
Dean: Mickey Shachar, PhD
Director, PhD Program: Ryan Dwight, PhD
Committee Chair: Frank Gomez, PhD
Committee Member: Ralph Garcia, PT, PhD
Committee Member: Carlos Cardillo, PhD

ProQuest Number: 13898408

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Copyright © 2018 Chad Woodard

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Abstract
Running as a form of exercise has increased dramatically in recent years, leading the incidence
of injury during a running program to increase concomitantly. Recently a trend of running
barefoot has emerged and gained popularity in an effort to mitigate this injury risk. Little
empirical evidence exists to demonstrate a reduced risk of injury. The purpose of this study was
to measure the injury incidence between barefoot and shod runners to determine the reported
incidence of injury between groups. A sample of 545 subjects completed a survey answering
questions about their running and injury history. Statistical analysis was performed showing
strong correlation of reduced reports of injury in the barefoot group. Further analysis performed
matching 21 barefoot runners with 21 shod runners resulted in significantly decreased reports of
injury in the barefoot running group (p = 0.011). This data suggests that running with a barefoot
strategy decreases the risk of injury in a running population, but more research is required to
support these findings including prospective longitudinal experimental designs with larger
samples.
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Biographical Sketch
Dr. Chad Woodard holds multiple degrees and certifications in sports and ortho Physical
Therapy. Strengthened by over a decade of clinical experience, Chad has developed the skill and
reputation to be a widely sought after physiotherapist across the NYC area as well as
internationally. While his clinical expertise is broad, Chad specializes in treating runners,
triathletes, dancers, and men with pelvic floor dysfunction. His first love, however, is mentoring
and collaborating with his exceptional team of brilliant physios.
Chad is also a competitive athlete. After several years as a professional dancer, he began
his journey as an endurance athlete having competed in multiple marathons, Ironman level
triathlons, and other extreme endurance events.
If you ask Chad, he will tell you that creating his company, Symbio Physiotherapy, and
witnessing the growth of this team is his greatest achievement--something far more important
than degrees, certifications, or accolades. May he never forget, and may all who encounter the
Symbio team know that joy and find the mutual growth that has been built.
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Dedication
This manuscript, a reflection of over 8 years of learning and efforts, is dedicated to those
in my life who have stood by my side with unwavering commitment, support, and respect as I
am allowed to dream of a brighter future and live my vision. Those select few individuals know
well their place and contribution to this work, not only evident in this manuscript, but in the long
journey bringing us to this day as well as the vision and focus to see where we will go together.
Without them, their belief in me and ability to remind me of my capabilities, I would be a simple
shell of who I am now allowed to be. To these select few, I bow deeply to who they are, who
they remind me to be, and what we will become together.

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Acknowledgements
To my Mother who always told me I could be anyone and anything I wanted to be, as
long as I was happy. Your wisdom and love laid the stones that started my journey and allowed
me to go confidently where I needed to be without fear.
To my fiancé and future husband, so much of what I do is because of your support and
encouragement. In your eyes I see the man I aspire to be, and with you by my side, know that all
is possible to achieve.
To my team at Symbio, know that through you I am given the gift of living my life’s
purpose and witness my dream unfold. Every day you challenge me to get better, and I can only
wish that I bring the same to you at every turn I take.
To my dissertation committee, I am grateful for your dedication and efforts to help me
grow and learn through this process. Especially though, I thank Dr. Ralph Garcia for his
unyielding and loving dedication to me and my passions through this process. Without his
guidance and efforts, this manuscript would not have occurred or been a work to be proud of,
and I am eternally grateful to him.

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Table of Contents
A Correlational Analysis of Reported Injury Incidence between Barefoot and Shod Runners...... 1
Copyright © 2018 Chad Woodard .................................................................................................. 2
Abstract ........................................................................................................................................... 3
Biographical Sketch ........................................................................................................................ 4
Dedication ....................................................................................................................................... 5
Acknowledgements ......................................................................................................................... 6
Table of Contents ............................................................................................................................ 7
List of Tables .................................................................................................................................. 8
List of Figures ................................................................................................................................. 9
A Correlational Analysis of Reported Injury Incidence between Barefoot .................................. 10
Chapter 1: Introduction ................................................................................................................. 10
Chapter II: Problem Statement and Research Question ................................................................ 16
Problem Statement .................................................................................................................... 16
Research Question .................................................................................................................... 17
Chapter III: Literature Review ..................................................................................................... 18
Biomechanics of Running ......................................................................................................... 18
Various Footstrike Patterns and Kinematic/Biomechanical Implications ................................ 19
Common Injuries ...................................................................................................................... 24
Theoretical Orientation and Conceptual Framework ................................................................ 27
Hypothesis................................................................................................................................. 31
Chapter IV: Methodology ............................................................................................................ 32
Research Design........................................................................................................................ 32
Study Population ....................................................................................................................... 32
Data Collection Tools ............................................................................................................... 33
Variables - Independent and Dependent Variables ................................................................... 33
Statistical Analysis .................................................................................................................... 34
Chapter V: Data Analysis and Presentation of the Results .......................................................... 36
Descriptive Statistics ................................................................................................................. 36
Bivariate and Multivariate Statistics ......................................................................................... 41
Chapter VI: Discussion, Conclusions and Implications of research ............................................ 48
Interpretation of Results ............................................................................................................ 48
Limitations ................................................................................................................................ 53
Recommendations for Future Research .................................................................................... 55
Advancement for the Field and Conclusive Summary ............................................................. 55
References ..................................................................................................................................... 57
Appendix A: Survey for Data Collection...................................................................................... 71
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List of Tables
Table 1. Summary of biomechanics between barefoot and shod conditions
Table 2. Study variables and level of measurement
Table 3. Demographic statistics for study population n=545 (total number of responses = 564)
Table 4. Descriptive statistics including number of injuries, surgical history and previous injury
Table 5. Running duration, self-reported experience level, and volume per week.
Table 6. Running style, running surface, race history, and fastest race pace.
Table 7. Logistic regression model comparing individual variables with associated risk of injury
Table 8. Age-Gender-BMI Matched Analysis: Results from the (multivariate) binomial

regression analysis
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List of Figures
Figure 1. Types of minimalist shoes.
Figure 2. Examples of motion control shoes.
Figure 3. Images of three different types of foot strikes with running.
Figure 4. Barefoot and shod running graph of peak forces during gait cycle.
Figure 5. Conceptual framework

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A Correlational Analysis of Reported Injury Incidence between Barefoot and Shod Runners
Chapter 1: Introduction
Running as a form of recreational exercise has increased dramatically in the past 35 years
(Lynch & Hoch, 2010) (Murphy, Curry, & Matzkin, 2013) and while advances have been made
in sports medicine and shoe design, the rate of injury has remained mostly unchanged in the past
30 years (Daoud et al., 2012) (Van Gent et al., 2007) (Murphy et al., 2013). Following the
publication of the popular book Born to Run: A Hidden Tribe, Superathletes, and the Greatest
Race the World has Never Seen (McDougall, 2011) running barefoot has become a popular
option for recreational runners as a method to prevent injuries, despite the lack of evidence
supporting this theory (Davis, 2014) (Tam, Astephen Wilson, Noakes, & Tucker, 2014) (Fong
Yan, Sinclair, Hiller, Wegener, & Smith, 2013) (Collier, 2011). The current body of literature
does not conclusively demonstrate which type of running, barefoot or shod (with shoes), has a
decreased incidence of injury (Daoud et al., 2012; Davis, 2014; Fong Yan et al., 2013; Hart &
Smith, 2008; Jungers, 2010; Lynch & Hoch, 2010; Moody, Hunter, Ridge, & Myrer, 2018;
Murphy et al., 2013; Squadrone & Gallozzi, 2009; Tam et al., 2014, 2017; Van Gent et al., 2007;
Wallace, Koch, Holowka, Lieberman, & Wallace, 2018), a question intended to be answered by
this study.
Humans have been evolving as endurance runners for millions of years as a means of
survival (Bramble & Lieberman, 2004; Krabak, Hoffman, Millet, & Chimes, 2011), utilizing
capabilities for thermoregulation (Ruxton & Wilkinson, 2011) as well as biomechanical and
anatomical advantages to maximize efficiency of the organism (Lieberman & Bramble, 2007;
Lieberman, 2012; Lieberman et al., 2010). The evolution of humans as runners became critically
important for survival due to their ability to endure prolonged stretches of exercise as opposed to
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short bursts of speed when compared to other land-based sprinting mammals (Bramble &
Lieberman, 2004). These evolutionary advantages allowed humans to become uniquely
designed for hunting and survival, as they were suited to outrun their prey into exhaustion
(Bramble & Lieberman, 2004; Krabak et al., 2011; Lieberman & Bramble, 2007; Ruxton &
Wilkinson, 2011).
Anthropological studies performed on the human foot have provided evidence to the
theory that humans have evolved as endurance runners as compared to other bipedal primates
(Klenerman & Wood, 2006; McDougall, 2011). The human foot has developed specific
anatomical structures ideal for a running mode of locomotion including the strucutre of the
skeletal system as well as the elastic storing characteristics of the soft tissue system (Bramble &
Lieberman, 2004; Klenerman & Wood, 2006; Lieberman & Bramble, 2007; McDougall, 2011).
The skeletal system properties include the combined motions of the subtalar joint and midtarsal
joint complex allowing the foot to pronate and supinate, modifiable to uneven surfaces and
terrain (Klenerman & Wood, 2006). The soft tissue properties include structures such as the
Achilles tendon and the spring ligament, which provide the opportunity for the storage of elastic
energy, providing a higher level of efficiency and economy of energy during edurance running
(Klenerman & Wood, 2006; Lieberman & Bramble, 2007; McDougall, 2011). These structures,
when rapidly placed under tension, store kinetic energy, which is then released to propogate
forward propulsion of the subject. Similar structures in primates are not as well adapted, leading
anthropologists to belive that the human foot has evolved specifically for the purpose of running
locomotion (Klenerman & Wood, 2006; Krabak et al., 2011; Lieberman & Bramble, 2007;
Lieberman, 2012; McDougall, 2011).

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The first evidence of shoes was found in samples taken from the Paleolithic era and date
between 5,000 and 10,000 years old (Cavanagh, 1980; Gilligan, 2010). The shoes found in this
era are described as simple soft material, often leather soled with a string to attach it to the foot,
and were used for rudimentary protection of the foot from damage to the plantar surface and
frostbite in cold climates (Davis, 2014).
Athletic shoes, as can be defined in modern culture, began to appear around the early
1800’s, undergoing significant changes and modifications throughout the years (Ly, Alaoui,
Erlicher, & Baly, 2010a; Vanderbilt, 1998). Rubber soles were added to shoes in 1832 for the
purpose of improved durability, followed by the addition of vulcanized rubber in 1868 allowing
a flexible sole with tread. It was at this time that the term “sneakers” was coined as the shoes
made little noise and allowed one to sneak up on another person (Cavanagh, 1980). In 1895, the
first running shoe was developed featurning metal spikes on the plantar surface of the shoe,
followed by the creation of the first cushioned running shoe in 1964 (Cavanagh, 1980). From
that first cushioned running shoe, variations and enhancements were made in 1972 with the birth
of Nike® (Vanderbilt, 1998). Since that time, the running shoe industry has created increasingly
complex shoes featuring multiple density foams, elaborate motion control structures, and
computer chips to alter the density of the sole based on environmental changes and in-vivo
endocrine measurements of the wearer (Davis, 2014; Ly, Alaoui, Erlicher, & Baly, 2010b).
More elaborate and complex shoes have been theorized to cause more injury than they
are able to prevent. Additional cushioning and support may result in decreased tissue tolerance
to mechanical stress and decreased intrinsic arch support of the runner, or support provided by
the person’s own musculoskeletal system (Davis, 2014; Lieberman et al., 2010; McDougall,
2011; Tam et al., 2014). There are some studies that paradoxically find a positive correlation
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between increased cost of the shoe to injury rates in runners (B Marti, Vader, Minder, & Abelin,
1984; Robbins & Waked, 1997).
Despite the technological advances in the enterprise of foot wear, there has recently been
a movement in the running community to return to the origins of shoe wear, leading many
runners to opt for a more minimalist shoe design or a barefoot strategy (Davis, 2014; Jungers,
2010). This is due to some runners believing that a return to a barefoot strategy would take
advantage of the foot’s anatomical structure, considered to be more natural, and therefore a
possible means to reduce injury. A minimalist shoe has little to no cushioning and contain a soft,
ultra-flexible midsole designed to recreate a barefoot running approach without exposing the foot
to the external environment (Bonacci et al., 2013; Cauthon, Langer, & Coniglione, 2013). The
usage of minimalist shoes is measured to be more energy efficient and economical during
running when compared to traditional running shoes, which might futher explain the increased
prevalance of this type of shoe (Perl, Daoud, & Lieberman, 2012). This minimalist shoe
movement has been progressed due to the body of research showing no measurable decrease in
running injury despite the advances in technology and shoe advancement (Daoud et al., 2012;
Davis, 2014; Van Gent et al., 2007).
Figure 1. Types of minimalist shoes. Pictured on the left are Vibram shoes designed to
mimic a glove for the foot and provide no external support. Pictured on the right is an
example of a minimal racing-flat shoe. This type of shoe has little to no support in the
sole of the shoe allowing the foot to move freely, similar to a barefoot experience.
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Figure 2. Pictured above are two examples of motion control shoes, presenting with
larger and thicker soles designed to support the arches of the foot as well as correct for
anatomical abnormalities.
Trends are being observed in subcultures of endurance running towards a barefoot or
mininalist strategy (shoe type designed to mimic barefoot conditions) due to the belief that the
increasingly complex and supportive shoe design is contradictory to the anatomical structure of
the foot, naturally evolved for shock absorption and uneven surface adaptation (Davis, Rice, &
Wearing, 2017; Davis, 2014; Klenerman & Wood, 2006; McDougall, 2011; Tam et al., 2017;
Tenforde, Ruder, Jamison, Singh, & Davis, 2018). Evidence exists demonstrating an improved
efficiency of biomechanics when running barefoot as compared to shod (Tam et al., 2014), but
concerns about injury related to barefoot running are prevalent (Murphy et al., 2013). With a
lack of empirical evidence demonstrating a measurable difference between the incidence of
injury between conditions, current prescription and personal choice of shoewear while running is
based on opinion and theory instead of evidence (Crevier, 2009; Davis, 2014; Hart & Smith,
2008; Jungers, 2010; Krabak et al., 2011; Murphy et al., 2013; Tam et al., 2014; Van Gent et al.,
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2007). Former attempts at shoe type prescription based on foot structure presentation has been
measured to be ineffective and overly simplistic (Ryan, Valiant, McDonald, & Taunton, 2011)
leading healthcare providers unable to prescribe types of shoe wear for the purpose of injury
prevention.
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Chapter II: Problem Statement and Research Question
Problem Statement
Research has demonstrated injury incidence rates in shod runners (Brund et al., 2017;
Reinking, Austin, & Hayes, 2010; Reinking, Hayes, & Austin, 2012; Reinking, 2006; Tam et al.,
2017; Taunton et al., 2002, 2003; Wallace et al., 2018) as well as barefoot runners (Crevier,
2009; Davis et al., 2017; Davis, 2014; Hart & Smith, 2008; Hollander, Hamburg, Zwaard,
Ziekenhuis, & Zech, 2017; Moody et al., 2018; Tam et al., 2017; Tenforde et al., 2018). The gap
in the literature is a study that examines both populations simultaneously to determine the
relative risk of injury between conditions (Collier, 2011; Crevier, 2009; Davis et al., 2017;
Davis, 2014; Hart & Smith, 2008; Hollander et al., 2017; Jungers, 2010; Krabak et al., 2011;
Moody et al., 2018; Murphy et al., 2013; Tam et al., 2017, 2014; Van Gent et al., 2007; Wallace
et al., 2018). In a 2017 systematic review (Hollander et al., 2017), no evidence was found to
demonstrate injury incidence differences between barefoot and shod runners. This current study
aims to fill that gap by answering the question regarding injury incidence rates between the
populations of barefoot and shod endurance runners. Questions remain to be answered on this
topic including injuries associated with shoe wear, what the impact on injury is when a runner
chooses a minimalist shoe as opposed to traditional shoe or barefoot, as well as considerations
with the surface on which a runner chooses to run.

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Research Question
RQ I: For runners, is there a significant difference in incidence of reported injury between
barefoot and shod conditions?

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Chapter III: Literature Review
Biomechanics of Running
The gait cycle is broken down into 4 phases including stance phase, early swing, mid
swing, and late swing, with the most significant biomechanical variations between barefoot and
shod runners occuring during the stance phase (Lohman, Balan Sackiriyas, & Swen, 2011).
Forefoot striking (FFS), midfoot striking (MFS), and heel striking (HS) are possible options for a
runner to demonstrate when they are initiating the stance phase of the gait cycle (Figure 3). In
the HS pattern, the runner makes initial contact on the ground with the heel and then follows by
placing the forefoot portion on the ground, MFS pattern is defined as the entire foot landing on
the ground simultaneously, while FFS pattern is when the front portion of the foot makes the
initial contact which is then followed by the heel portion of the foot touching the ground
(Lieberman et al., 2010; Lohman et al., 2011). The portion of the foot making initial contact
with the ground is the most significant difference observed between barefoot runners and shod
runners, with barefoot runners demonstrating a FFS or MFS while shod runners demonstrate a
HS (Hollander, Argubi-Wollesen, Reer, & Zech, 2015)(Collier, 2011; Daoud et al., 2012; Hall,
Barton, Jones, & Morrissey, 2013; Jungers, 2010; Lieberman et al., 2010; Lohman et al., 2011;
McDougall, 2011; Murphy et al., 2013; Tam et al., 2014; Van Gent et al., 2007).
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(a) (b) (c)

Figure 3. Forefoot strike (a) and midfoot strike (b) more
common in barefoot runners, and heel strike (c) more
common in shod runners (Lieberman et al., 2010)
HS pattern is more commonly seen in shod runners (Hollander et al., 2015) (Kasmer, Liu,
Roberts, & Valadao, 2013; Larson et al., 2011) which is thought to be observed due to the
additional cushioning in the heel-portion of the shoe allowing for absorption of greater amounts
of impact forces (Lieberman et al., 2010). Runners who employ a barefoot strategy have been
observed to use a pattern of FFS or MFS (Hollander et al., 2015)(Hasegawa, Yamauchi, &
Kraemer, 2007; Hatala, Dingwall, Wunderlich, & Richmond, 2013; Lieberman et al., 2010;
Squadrone & Gallozzi, 2009). When a FFS or MFS pattern is used, a larger portion of surface
area initially comes into contact with the ground as compared to a HS pattern, which reduces the
focal point of pressure on the heel and decreases the amount of force going through surrounding
ligaments and joints (Wit, Clercq, & Aerts, 2000).
Various Footstrike Patterns and Kinematic/Biomechanical Implications
Ground reaction force (GRF) is defined as the force exerted by the ground on a body
when physical contact occurs (Adelson, Yaggie, & Buono, 2005). The amount of that force
changes depending on several variables including stride length, running speed, shoe
characteristics, inclination, and stiffness of the ground surface (Lohman et al., 2011; Murphy et
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al., 2013). When plotted graphically against time, the GRF is normally measured as a bell-
shaped curve with the peak force exerted when the sole of the foot is in contact with the ground
(Lieberman, 2012; Lieberman et al., 2010; Murphy et al., 2013).
There is a significant difference between the GRF of a barefoot runner compared to shod
runner (Divert, Mornieux, Baur, Mayer, & Belli, 2005.; Lieberman et al., 2010; Lohman et al.,
2011; Squadrone & Gallozzi, 2009). A runner using a barefoot strategy commonly uses a FFS
pattern, creating smaller collision forces with the ground and therefore a smaller GRF than a
shod runner (Lieberman et al., 2010; Squadrone & Gallozzi, 2009)(Hatala et al., 2013). The
shorter amount of time a runner is in contact with the ground will also decrease the GRF which is
seen in the shorter stance phase measured in barefoot runners (Divert et al., 2005.; Lohman et al.,
2011). Stride length and stride frequency are also measurably different between the two
conditions affecting GRF (Thompson, Gutmann, Seegmiller, & McGowan, 2014). A measured
decrease stride length and stride frequency in barefoot conditions lead to a decreased GRF,
proposed to decrease risk of injury in the runner (Thompson et al., 2014).
Another force that is different between barefoot and shod runners is the impact transient
peak force, which is a peak GRF that occurs in the first 50 miliseconds of stance phase
(Lieberman et al., 2010). In a barefoot runner that demonstrates a FFS pattern the peak impact
force is absent, indicating that this strategy does not exert the impact force on the subject
(Lieberman et al., 2010). In shod subjects with a RFS pattern, the GRF shows this peak impact
force (Figure 4). This force is a collision exerted on the lower extremeity of the subject,
approximately two to three times the runner’s body weight (Keller et al., 1996).
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Figure 4. Top graph: distinct impact peak at heel strike in shod runner. Bottom graph: absence
of impact peak in barefoot runner. Source: (Lieberman et al., 2010)
Loading rate is defined as the slope of the GRF versus time, and is another variable that
differs between barefoot and shod runners (Murphy et al., 2013). A runner under shod
conditions using a HS pattern will experience a three-fold increase in the average loading rate as
compared to a barefoot runner using a FFS pattern (Lieberman et al., 2010). The amount of
force experienced is measured to be statistically similar between conditions but the rate at which
that force is experienced is different. This increased rate of loading is theorized to be a causative
factor to injury in a population of shod runners (Davis, 2014; Lieberman et al., 2010). Increased
loading rate is consistently observed when a runner employs a rear foot strike pattern of contact,
regardless of being barefoot or shod (Lieberman et al., 2010). This suggests that the RF strike
pattern, which is most commonly seen in shod runners, produces this increased rate of loading
moreso than the presence or absense of shoes while running (Davis, 2014; Lieberman et al.,
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2010). Figure 4 graphically represents this measurement, demonstrating the more vertical slope
of increased force over time in a shod runner as compared to the less vertical slope of that
increased force in a barefoot runner.
The ratio between the maximum GRF and the maximum leg compression during contact
with the ground is defined as leg stiffness, which is another variable that differs between barefoot
and shod runners (Wit et al., 2000). A runner will adjust leg stiffness when running on different
types of surfaces. When running on a softer surface, such as a dirt trail, a runner will increase
leg stiffness while a runner on a harder surface will decrease leg stiffness (Ferris et al., 1998).
Runners on an uneven terrain will constantly change leg stiffness to maintain stability (Grimmer,
Ernst, Gunther, & Blickhan, 2008). When leg stiffness is measured as related to shoewear,
barefoot runners are found to demonstrate signifantly less leg stiffness as compared to shod
runners (Bishop, Fiolkowski, Conrad, Brunt, & Horodyski, 2006). This difference is theorized to
have implications regarding injury risks between populations stating that increased leg stiffness
will possibly lead to increased risk of injury (Bishop et al., 2006; Davis, 2014; Murphy et al.,
2013).
During a rearfoot strike pattern, the effective mass of the runner is increased due to the
dissapation of the translational kinetic energy (Chatterjee, Anindya; Garcia, 2000; Lieberman et
al., 2010). This dissapation of translational kinetic energy may cause injury to the rearfoot
striking runner due to the increased ankle stiffness required, which is measured to be lower in a
forefoot striking runner (Chatterjee, Anindya; Garcia, 2000). During a FFS pattern, the
translational kinetic energy is converted into rotational kinetic energy, allowing for improved
energy storage and recovery in the Achilles tendon and arch of the foot, theorized to reduce the
risk for injury (Chatterjee, Anindya; Garcia, 2000; Lieberman et al., 2010). Conversion of this
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energy is more efficient in the barefoot runner employing a forefoot strike pattern due to
increased energy efficiency during ground collision (Divert et al., 2008; Lieberman et al., 2010).
Decreased ankle stiffness meausured in forefoot strike running is theorized to reduce the risk of
injury as compared to rearfoot striking running due to the variations in force dissapation through
the musculoskeletal system (Divert et al., 2008, 2005; Lieberman et al., 2010). Changes in
plantar pressure are also measurably different between barefoot and shod runners (Maiwald et
al., 2008) theorized to potentially change incidence of injury.
Table 1. Summary of biomechanics between barefoot and shod conditions
Factor Barefoot running Shod Running
Strike Pattern Forefoot Rearfoot
Impact transient of GRF Minimal High
Loading rate 3X less than shod 3X higher than barefoot
Energy efficiency Higher Lower
Leg stiffness Lower Higher
Ankle stiffness Lower Higher
The kinematics and biomechanics vary between barefoot and shod conidtions (Lieberman
et al., 2010) but do not vary between traditional running shoes and minimalist running shoes
designed to mimic barefoot conditions (Bonacci et al., 2013). Bonacci et al. (2013) found that
barefoot running was different to all shod conditions by decreasing the amount of work done at
the knee and ankle joints as well as improving efficiency when compared to shod conditions, but
found no difference between types of running shoes worn by the subjects. This would suggest
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that the running style, and risk of injury, will be similar between runners wearing traditional
shoes and minimalist shoes, but different from barefoot subjects (Bonacci et al., 2013).
Further evidence suggests that barefoot running is more efficient and economical as
compared to shod running which is theorized to reduce risk of injury (Warne & Warrington,
2014)(Tam et al., 2014). A meta-analysis of thirteen studies on running efficiency between
conditions (Cheung & Ngai, 2014) found that decreased oxygen consumption during barefoot
running was consistent, indicating a decreased workload of the body and increased efficiency.
This increased efficiency as measured by oxygen consumption can be attributed to decreased
injury theoretically, but the authors found significant bias in other meausrements warranting
further study to adequately demonstrate improved energy efficiency in a barefoot running
population (Cheung & Ngai, 2014).
Common Injuries
The most common injuries reported with shod running include patelofemoral pain
syndrome, tibial stress fractures, plantar fasciitis, and Achilles tendinitis (Barton, Levinger,
Menz, & Webster, 2009; Bennell et al., 2004; Knobloch, Yoon, & Vogt, 2008; Milner, Ferber,
Pollard, Hamill, & Davis, 2006; Ribeiro et al., 2011; Zadpoor & Nikooyan, 2011). Knee pain is
a commonly reported injury (Van Gent et al., 2007) with patellofemoral pain syndrome (PFPS)
accounting for 20% of all running related injuries (Lohman et al., 2011). This PFPS is theorized
to be caused in part by excessive eversion of the foot from cushioned shoes resulting in
malalignment of the patella during running (Barton et al., 2009). Plantar fasciitis affects up to
25% of runners (Ribeiro et al., 2011) but is theorized to be lower in barefoot runners due to the
lack of impact on the heel where the plantar fascia attaches. With a smaller GRF and leg
stiffness during barefoot running, the lower extremity experiences decreased stress and possibly
RUNNERS 25
decreased risk for injury (Ferris et al., 1998; Wit et al., 2000). Tibial stress fractures are
theorized to be caused by the increased GRF experienced during running, which has implications
for the barefoot running movement, but no correlation has been found establishing the
correlation (Bennell et al., 2004). Tibial stress fractures are however a common injury in the
running population (Milner et al., 2006).
Little evidence exists on the injuries correlated with barefoot running, but inferences can
be made about the risks based upon the measured change in kinematics in a barefoot running
population (A. R. Altman & Davis, 2012). Barefoot runners are generally forefoot strikers
resulting in reduced rates of loading, and demonstrate reduced stride length also decreasing the
load, both factors considered to decrease the risk of injury (Bowser & Hamill, 2000; Pohl,
Hamill, & Davis, 2009; Pohl, Mullineaux, Milner, Hamill, & Davis, 2008). Forefoot striking can
be correlated with Achilles tendinopathy and metatarsal stress fractures, which are possible
injury risks for those running barefoot or with a forefoot striking pattern (Williams, McClay, &
Manal, 2000).
Many theorize that the injuries related to barefoot running are caused by an aggressivley
rapid implementation time-line transitioning from shod to barefoot, thus not allowing for the
body to properly adapt to the altered demand of the activity (Davis, 2014). A measurable and
significant change in biomechanics was found in a sample of shod runners transitioning to
barefoot simulated conditions in six weeks of training under the barefoot simulated condition
(Khowailed, Petrofsky, Lohman, & Daher, 2015). A gradual increase in training time and
distance over the six weeks in the barefoot simulated shoes resulted in changes in muscular
recruitment and foot striking pattern indicating the time frame of 6 weeks to be adequate for
subjects to modify their running strategy (Khowailed et al., 2015).

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When running barefoot, or with a minimal shoe, the foot strike migrates from the heel of
the foot towards the midfoot or forefoot (Davis, 2014) (Murphy, Curry, & Matzkin, 2013) (Hall,
Barton, Jones, & Morrissey, 2013). This change in foot strike patterns has been shown to
decrease forces acting through the body and is theorized to decrease risk of injury (Davis, 2014)
(Murphy, Curry, & Matzkin, 2013) (Hall, Barton, Jones, & Morrissey, 2013).
Recent research has shown that there is no measureable difference in injury incidence
rate between trials of minimalist shoe wear and traditional shoe wear, or the biomechanics
between the conditions, but indicate differences between the conditions of true barefoot and all
shod conditions (Bonacci et al., 2013; Grier et al., 2016; Hollander et al., 2015). When
measuring injury incidence rate between minimalist running shoe wear and traditional running
shoes when the subjects were statistically controlled for outside variables, no significant
difference was found between conditions (Grier et al., 2016). This study did not however
include the condition of barefoot running, only minimalist shoes versus tranditional shoes. Other
research measuring the biomechanical changes between conditions found the greatest difference
between true barefoot conditions versus all shod conditions, including barefoot simulated
conditions (Bonacci et al., 2013; Hollander et al., 2015).
No research has been published demonstrating variability of injury incidence rate
between barefoot and shod conditions, with one exception in 2012. Traditionally shod runners
were found to report higher incidence of injury as compared to those wearing minimalist shoes
or barefoot strategies (Goss, 2012). Exclusion criteria for this study included removing subjects
who had changed their shoe wear within the last year of training (Goss, 2012), but previously
sited research demonstrated a significant change in foot strike pattern and biomechanics after
only 6 weeks of altered shoe wear (Khowailed et al., 2015). This timeline exclusion criteria
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potentially skewed the results. Additional limitation of this study was the low number of true
barefoot respondents, 16 subjects of the total 904 used for analysis (Goss, 2012). Knowing that
there are measureable changes between true barefoot strategy and shod conditions (Bonacci et
al., 2013; Grier et al., 2016; Hollander et al., 2015), as well as the measured change in running
mechanics after six weeks of implimentation (Khowailed et al., 2015) changes the variables for
future research, namely the following study.
Theoretical Orientation and Conceptual Framework
One theory involving running biomechanics states that alternating tensile forces may be
attributed to joint positioning in the foot. In a study observing tensile forces acting on the
Achilles tendon (Wyndow, Cowan, Wrigley, & Crossley, 2010), the authors summarized that
varying forces on the tendon may be a result of rear-foot positioning and potentially modified by
use of foot orthotic. However, the available data collection method for this research in rear-foot
biomechanics does not have a high level of validity, so the results are easily disputed. As an
alternative, the authors theorized that improvements in tensile forces as a result of orthotic
prescription are possibly due to an altered neuromuscular component for the subject in study.
They theorized that the sensory input of the orthotic provides sufficient stimulus to the individual
so that motor recruitment strategies are altered due to modified neuronal input (Wyndow et al.,
2010).
Similarly, another study (Proctor & Holmes, 2010) discussed the role of neurological
input on normal gait mechanics and how they theoretically affect coordinated gait production.
They discussed that organisms are subject to and controlled by both feedforward and feedback
signals. Feedforward signals refer to input by the central nervous system in conjunction with
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prereflexive mechanical reaction forces to provide information to the organism for proper motion
planning and execution. Feedback signals are described as information gathered by the body
during an activity allowing for the body to modify or correct the motion to suit the needs of the
activity. While this information is well established in neuroscience studies, the theoretical
influences refer to how the body is able to interpret and utilize the information gathered. The
higher the level of feedback obtained, the more accurately the body will adjust and modify the
activity in question (Proctor & Holmes, 2010).
When an individual alternates between shod and barefoot conditions, the above-
mentioned theories would support the concept that said individual will have an altered
neurologic input and therefore an altered neuromotor response. As discussed by (Wyndow et al.,
2010), the alteration of shoe wear may potentially change the neurologic input gathered by an
individuals body and nervous system. It can therefore be assumed that variations in shoe wear,
or the absense of shoes, will alter the neurological input received by that individual. An example
of this change in input would be varying levels of proprioception. If a subject has less physical
material separating their foot from the ground surface, they will have an enhanced ability to
receive proprioceptive feedback versus a subject wearing a thick-soled shoe. This increased
level of proprioception can theoretically allow the subject to self-correct faulty or suboptimal
biomechanics. Concerning the feedback system described above (Proctor & Holmes, 2010), it is
again theorized that those running barefoot will be provided with more accurate feedback input
than those in thick-soled running shoes. Proprioception is one type of this feedback. Feedback
can be provided by sensory organs in the joints as well as the skin. Based on these theoretical
constructs, it is presumed that those running barefoot will have an enhanced ability to perceive
the ground and modify biomechanics as necessary (Proctor & Holmes, 2010).
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This theoretical framework is further supported by a study demonstrating altered
variability in knee and ankle biomechanics when the shoe wear was changed from hard shoe to
soft shoe and finally no shoe (Kurz & Stergiou, 2003). The authors found that when the above
conditions were changed, so too was the motor output of the subjects studied, indicating a
change in the motor patterns. It is suggested that this change might be due to the altered sensory
information obtained by the subjects, resulting in a subsequent change in biomechanics and
motor output (Kurz & Stergiou, 2003).
These concepts form the theoretical basis for the current research study as they are rooted
in the overarching Motor Learning Theory, stating that movement patterns are theoretically
dictated by proprioceptive feedback that is then interpreted by the individuals central nervous
system and then sent as a movement strategy appropriate for the task and environment
(Tagliabue & McIntyre, 2014). The altered proprioceptive feedback perceived by the individual
when running barefoot will be transmitted to the central nervous system, then causing an altered
motor response. The strength of this relationship takes massed practice for the individual to
demonstrate a significant and steady change in the motor output.

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Conceptual Framework
Shoe type
Barefoot
Minimalist
Traditional
Foot Strike
Training Surface
Pattern
Asphalt
Rearfoot
Dirt/trail
Midfoot
Treadmill
Forefoot
Injury
Incidence
Foot, Ankle,
Lower leg, Knee,
Thigh, Hip, Low
back
Demographics Running History
Gender Weekly mileage
Age Training pace
Height Years running
Weight Current strategy
Cross Training
Cycling
Swimming
Weight training
Other
Figure 5:The conceptual framework includes the independent variables of demographics, foot
strike pattern, shoe type, training surface, running history, and cross training activity. The
dependent variable is injury incidence rate as organized by body region: foot, ankle, lower leg,
knee, thigh, hip, and low back.
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Hypothesis
RQ I: For runners, is there a significant difference in incidence of reported injury between
barefoot and shod conditions?
H0: For runners, there is no statistically significant difference in incidence of reported injury
between barefoot and shod conditions.
Halt: For runners, there is a statistically significant difference in incidence of reported injury
between barefoot and shod conditions.

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Chapter IV: Methodology
Research Design
The research design was a non-experimental epidemiology study of reported foot injury
using an exploratory survey designed to identify and demonstrate measurable correlational
associations between independent variables and report of injury. No physical contact was
performed with the subjects aside from the survey participation.
Study Population
Subjects were recruited through online platforms as well as local outreach to running
clubs. Running groups local to the New York City area were recruited through email and social
media. Groups contacted were Front Runners of New York, a local running group consisting of
800 members, as well as the New York Road Runners. A link to the survey was posted with
online running forums, especially forums geared towards a barefoot running population. Online
recruitment was not limited to the New York City area but rather include runners from all
regions of the United States. Inclusion criteria will include individuals who participated in a
running program over the past year and are ages 18-70. All shoe type selections were included,
consisting of barefoot, barefoot simulation, minimalist shoes, neutral shoes, and motion control
shoes. Exclusion criteria included subjects with a history of orthopedic surgery of the lower
extremity or lumbar spine, or orthopedic diseases and disorders including endocrine diseases.
Cohen’s power analysis was conducted with a medium effect size for the statistical tests
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performed. The level of significance will be set at α = .05 and β = .20 (Portney & Watkins,
2009).
Data Collection Tools
Data was collected by a survey in the online platform Qualtrics. Prior to data collection,
the survey was evaluated by a panel of 17 experts in the field to establish content validity and
reliability. 10 of these experts were running coaches and 7 of the experts were academicians
familiar with survey design and statistical analysis. These 17 experts were asked to complete the
survey and provide feedback regarding appropriateness of questions asked, ease of completion,
and recommendations for improvements. This feedback was considered and implemented as
was appropriate. The survey was then sent again to the same 17 experts for review and
discussion. All 17 experts completed the review of the survey and provided feedback via email
and phone conversations for both trials. The feedback provided from the two rounds of
validation was utilized in creation of the final survey before dissemination to study subjects.
Variables - Independent and Dependent Variables
Independent variables of the study are demographics, shoe type, training surface, running
history, and cross training activity. Demographic information gathered included gender, age,
weight, and height. Foot strike pattern is a nominal variable including rearfoot, midfoot, and
forefoot patterns. Shoe type is a nomial variable including barefoot, minimalist (barefoot
simulation), and traditional running shoe. Training surface is a nominal variable including
asphalt and dirt/trail surfaces. Running history data was collected in the following categories:
weekly volume, training pace, years running, and time spent using preferred running strategy
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which are all ordinal variables. The dependent variable is injury incidence as organized by body
region: foot, ankle, lower leg, knee, thigh, hip, and low back.
Table 2. Study variables and level of measurement
Independent Variables Level of Measurement
Gender Nominal
Age group Ordinal
BMI Ordinal
Shoe Type Nominal
Training Surface Nominal
Running History Ordinal
Dependent Variable Level of Measurement
Injury Incidence Ratio
Statistical Analysis
Contingency tables were constructed and analyzed between the nominal independent
variables and ratio dependent variables. Demographics, shoe type, training surface, and cross
training are all nominal independent variables used in the cross tabulation contingency tables and
compared with injury data. Chi-squared test was used to measure relationships between these
variables. The independent variable of shoe type, a nominal variable, was also compared to the
dependent variable of injury incidence, a ratio variable. Statistical tests to measure the
relationship between the independent and dependent variable was an independent sample t-test as
well as a Wilcoxon-Mann Whitney test. The survey also gathered data to allow the dependent
variable of injury incidence to be categorized by body region, which is a nominal variable. Chi-
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squared test was used for this analysis. A multiple regression analysis was performed between
all nominal independent variables and interval independent variables to determine relationships
as compared to the ratio dependent variable of injury incidence. All analyses were conducted
using the statistical programming language R. All tests were two sided with a p-value <0.05, the
threshold for significance. Group matching and all statistical analyses were conducted using the
matchControls function in e1071 and R packages respectively.

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Chapter V: Data Analysis and Presentation of the Results
Descriptive Statistics
Descriptive statistics were first used to summarize the characteristics of the population.
Proportions were used to summarize categorical variables and median [range] or mean [standard
deviation] for continuous variables. Of 564 responses, 19 subjects were excluded from the study
due to meeting exclusion criteria or not completing the entire survey. Five-hundred and forty-
five subject’s data were utilized for the statistical analysis, of which 192 (35.23%) were male and
353 (64.77%) female, 284 (52.1%) were ages 18-39 with 261 (47.9%) being 40+, and BMI
(kg/m2) recorded at 151 (27.7%) >25, 63 (11.6%) at 25-30, and 331 (60.7%) at >30 (Table 3).
Table 3. Demographic statistics for study population n=545 (total number of responses = 564)
Gender: Q1 Male 192 (35.23%)
Female 353 (64.77%)
Age (years): Q2 18-39 284 (52.1%)
40+ 261 (47.9%)
BMI (kg/m2) <25 151 (27.7%)
25-30 63 (11.6%)
>30 331 (60.7%)
Of all subjects included in the study 247 (47.87%) did not report an injury during the last
year of training, 151 (29.26%) reported 1 injury, 87 (16.86%) reported 2 injuries, 27 (5.23%)
reported 3 injuries, and 4 (0.78%) reported 4 or more injuries. One-hundred twenty eight
(23.52%) identified as having a previous surgery, 409 (75.46%) denied previous surgery, and 5
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(0.92%) reported unsure of surgical history. Of the 128 (23.52%) reporting a surgical history,
none met the exclusion criteria as those subjects were removed from the sample. 125 (24.18%)
reported having a previous injury from running with 392 (75.82%) reporting not having a
previous injury (Table 4).
Table 4. Descriptive statistics including number of injuries, surgical history and previous
injury
Number of injuries (outcome) 0 247 (47.87%)
during the last year of 1 151 (29.26%)
training: Q23 2 87 (16.86%)
3 27 (5.23%)
>4 4 (0.78%)
Surgery history: Q33 Yes 128 (23.52%)
No 409 (75.46%)
Unsure 5 (0.92%)
Previous injury: Q12 Yes 125 (24.18%)
No 392 (75.82%)
Of the subjects surveyed, 173 (32.34%) reported running less than 5 years in total, 155
(28.97%) reported running for 6-10 years, and 207 (38.69%) longer than 10 years. Subjects were
asked to report their believed level of experience with 28 (5.24%) identifying as a beginner, 354
(66.3%) as somewhat/moderately experienced, and 152 (28.46%) identifying as very
experienced/professional level. Regarding running volume as measured by average days per

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week each subject ran over the past year, 91 (17.18%) reported 0-2 days per week, 208 (39.25%)
reported 3 days per week, 140 (26.42%) reported 4 days per week, and 91 (17.17%) reported 5 or
more days per week (Table 5).
Table 5. Running duration, self-reported experience level, and volume per week.
Running Duration (years): <5 173 (32.34%)
Q38 6-10 155 (28.97%)
>10 207 (38.69%)
Running experience: Q26 Beginner 28 (5.24%)
Somewhat/moderately 354 (66.3%)
experienced
Very experienced/ 152 (28.46%)
Professional
Running volume per week 0-2 91 (17.18%)
(days): Q6 3 208 (39.25%)
4 140 (26.42%)
5+ 91 (17.17%)
Table 6 describes shoe choice, surface runners chose most often, distances of races
subjects participated, and personal best running pace associated with respective race distances.
21 subjects (3.94%) indicated running barefoot or in a barefoot simulating shoe, 486 (91.01%)
reported wearing traditional shoes when running, 11 (2.06%) reported running both barefoot and
with traditional shoes at different times, and 16 (3%) reported running in barefoot simulation
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shoes as well as traditional shoes at different times. Reports of surfaces subjects ran on most
often revealed the following: 413 (78.7%) most often ran on asphalt or concrete, 49 (9.3%) ran
on an outdoor trail, 58 (11 %) ran on a treadmill, 3 (0.6%) on a track, 1 (0.2%) on grass, and 1
(0.2%) on synthetic turn grass. Participation in various distance races revealed 235 (45.2%)
competed in more than two races of 5K distance, 219 (42%) in more than one 10K, 254 (48.8%)
in more than one half marathon, 218 (41.9%) in one or more full marathons, and 41 (7.9%) in
one or more ultramarathon. For those indicating participation in a 5K race, personal best pace
for this distance was reported at 102 (27.8%) subjects running slower than a 10 min/mile pace,
83 (22.6%) at a 9 min/mile pace, 129 (35.1%) between a 7-8 min/mile pace, and 53 (14.4%)
faster than a 5 min/mile pace. For those indicating participation in a 10K race, personal best
pace for this distance was reported at 101 (34.5%) slower than a 10 min/mile pace, 64 (21.8%) at
a 9 min/mile pace, 101 (34.5%) at a 7-8 min/mile pace, and 27 (9.2%) faster than a 6 min/mile
pace. For those indicating participation in a half marathon race, personal best pace for this
distance was reported at 150 (43.2%) slower than a 10 min/mile pace, 74 (21.3%) between a 9-
10 min/mile pace, 64 (18.4%) between a 7-8 min/mile pace, and 59 (17%) between a 5-7
min/mile pace. For those indicating participation in a full marathon race, personal best pace for
this distance was reported at 81 (37.9%) subjects ran slower than an 11 min/mile pace, 42
(19.6%) at a 10 min/mile pace, 69 (32.2%) between 8-9 min/mile pace, and 22 (10.3%) subjects
reporting faster than a 7 min/mile pace.

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Table 6. Running style, running surface, race history, and fastest race pace.
Shoe choice Barefoot/ Barefoot-simulation 21 (3.94%)
Shoes 486 (91.01%)
I run both barefoot and with 11 (2.06%)
shoes on at different times
I run both barefoot-simulation 16 (3%)
and with shoes on at different
times
The surface that you run on Asphalt/Concrete 413 (78.7%)
most often: Outdoor trail 49 (9.3%)
Treadmill 58 (11 %)
Track 3 (0.6%)
Grass 1 (0.2%)
Synthetic turf grass 1 (0.2%)
How many times did you 5K (>2) 235 (45.2%)
participate in the following 10K (>1) 219 (42%)
distance races: Half marathon (>1) 254 (48.8%)
Full marathon (>0) 218 (41.9%)
Ultra marathon (>0) 41 (7.9%)
Personal best running pace +10 102 (27.8%)
for a 5K race (min/mile) Q28 9 83 (22.6%)
7-8 129 (35.1%)

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5< 53 (14.4%)
10K race (min/mile): Q29 +10 101 (34.5%)
9 64 (21.8%)
7-8 101 (34.5%)
6< 27 (9.2%)
Half marathon (min/mile): +10 150 (43.2%)
Q30 9-10 74 (21.3%)
7-8 64 (18.4%)
5-7 59 (17%)
Full marathon +11 81 (37.9%)
(min/mile):Q31. 10 42 (19.6%)
8-9 69 (32.2%)
7< 22 (10.3%)
Bivariate and Multivariate Statistics
Individual variables were next compared with associated risk of injury. Injury risk was
consolidated into a dichotomous variable, injured versus non-injured. The quantity of injuries
was not determined to be a relevant factor to the results. An Instance Relative Risk (IRR) was
performed at a 95% confidence interval with p-values reported. A p-value equal or lower than
0.05 was defined as statistically significant. Adjusted IRR was also performed only on the
variables found to be significant or strongly associated from the IRR and listed below.
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Variables found to have a non-significant p-value as related to report of injury included
duration of running (years), running volume per week, gender, age, surgical history, surface on
which running occurred, number of 5K races completed, number of half marathons completed,
number of ultra-marathons completed, and running pace reported for given race distances.
Variables found to have a strong correlation or a statistically significant correlation included
barefoot running, running experience, BMI, history of injury, and the number of 10K and full
marathon races completed.
Those reporting running with shoes (answering no to running barefoot) were found to
have a strong correlation to injury although not statistically significant (p = 0.074). That
relationship remained when running the adjusted IRR though a slightly weaker correlation was
found (p = 0.089). The experience level reported by the subjects was found to be a significant
variable. Those reporting themselves as an experienced runner were statistically significant to
report injury as compared to beginner runners (p = 0.024), while professional runners
demonstrated a strong correlation to injury risk as compared to beginners but non-significant (p =
0.071). When the adjusted IRR was performed, neither variable remained significant or strongly
associated. BMI between 25-30 was found to be statistically significant for injury risk (p =
0.036) when compared to <25 and that relationship remained when performing the adjusted IRR
with a p = 0.010. Reporting no history of injury was found to be significant for sustaining injury
(p = 0.015) and still strongly associated but non-significant after performing the adjusted IRR (p
= 0.054). Subjects who ran >1 10K race reported significantly higher injuries (p = 0.022) which
remained significant with the adjusted IRR (p = 0.036). Subjects who ran a full marathon
reported significantly higher injuries than those who had not run a marathon (p = 0.008) and
remained strongly associated yet non-significant with the adjusted IRR (p = 0.081).
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Table 7. Logistic regression model comparing individual variables with associated risk of
injury
Variable All participants (N=545 runners)

IRR [95% CI]/p-value Adjusted IRR [95% CI]/p-
value
Barefoot
Yes#
No 2.450 [0.916 6.554]/ 0.074 2.828 [0.853 9.376]/ 0.089
Running experience
Beginner#
Experienced 2.694 [1.141 6.363]/0.024 1.833 [0.726 4.630]/ 0.200
Professional 2.281 [0.933 5.579]/0.071 1.216 [0.448 3.301]/ 0.701
Duration of running
<5#
6-10 0.956 [0.613 1.491]/0.843 NA
11+ 0.811 [0.537 1.223]/0.317
Running volume per week
(days): Q6
0-2# 1.050 [0.637 1.731]/0.848 NA
3 1.108 [0.648 1.893]/0.708
4 1.263 [0.696 2.293]/0.443
5+
Gender
Male NA
Female 1.242 [0.865 1.784]/0.241
Age (years)
18-39 NA
40+ 1.104 [0.757 1.608]/0.608
BMI
<25#
<30 0.655 [0.442 0.972]/0.036 0.560 [0.360 0.873]/ 0.010
30+ 0.794 [0.450 1.403]/0.428 0.768 [0.404 1.463]/ 0.422
Surgery history
Yes#
No 0.800 [0.530 1.209]/0.29 NA
Injury history (Q12)
Yes#
No 0.601 [0.399 0.908]/ 0.015 0.634 [0.399 1.008]/ 0.054
The surface that you run on
with more than 50%: Q9, Q35,
Q36 Ref NA
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Asphalt/Concrete# 0.664 [0.313 1.407]/

Outdoor trail 0.285
Treadmill 0.702 [0.358 1.377]/
All others 0.304
2.603 [0.268 25.269]/
0.409
The surface that you run on
most often: Q9, Q35, Q36 NA
Asphalt/Concrete# Ref
Outdoor trail 0.689 [0.371 1.280]/ 0.239
Treadmill 0.809 [0.477 1.372]/ 0.431
All others 0.574 [0.095 3.472]/ 0.546
How many times did you
complete: Q8
5K Ref NA
High (>2) 0.895 [0.632 1.268]/ 0.533
Low (≤2)
10K
High (>1) Ref
Low (≤1) 0.662 [0.465 0.942]/ 0.022 0.644 [0.427 0.972]/ 0.036
Half marathon
High (>1)
Low (≤1) 0.751 [0.530 1.062]/ 0.105 NA
Full marathon
High (>0)
Low (=0) 0.618 [0.434 0.881]/ 0.008 0.685 [0.449 1.047]/ 0.081
Ultra marathon
High (>0)
Low (=0) 0.882 [0.461 1.688]/ 0.706 NA
Running pace for (min/mile)
5K 1.045 [0.930 1.174]/ 0.458 NA
10K 0.996 [0.871 1.138]/ 0.952 NA
Half marathon 1.006 [0.887 1.141]/ 0.924 NA
Full marathon 0.926 [0.791 1.084]/ 0.338 NA
Ultra marathon 1.160 [0.801 1.681]/ 0.431 NA
Further statistical analysis was perform comparing the same variables but with sample
sizes of equal numbers. The above numbers are meaningful and significant but the large
discrepancy between barefoot runners (n = 21) and shod runners (n = 486) was considered to
potentially skew the analysis. Twenty-one shod runners were matched to the 21 barefoot runners
RUNNERS 45
for variables of age, gender, and BMI as those variables are commonly used to match subjects
between groups (Saiedullah & Sha, 2017) and was appropriate for this analysis.
Variables now found to be non-significant as compared to risk of injury included running
volume per week, gender, age, BMI, surgical history, injury history, running surface, race
history, and best running pace for a given distance and were not included in the analysis.
Duration (years) of running was now found to be significant or strongly correlated. Subjects
reporting running between 6-10 years as compared to those running less than 5 years were less
likely to report injury though not at a statistically significant value (p = 0.085). This association
remained when performing the adjusted IRR with a weaker correlation (p = 0.190). Subjects
reporting running longer than 11 years as compared to those running less than 5 years were less
likely to report injury at a statistically significant value (p = 0.024). This association remained
when performing the adjusted IRR though the relationship then became non-significant but
strongly associated (p = 0.063).
Barefoot running versus shod running became strongly correlated to injury reports and
statistically significant. Subjects reporting running barefoot were found to be significantly less
likely to report injury (p = 0.014). The relationship remained statistically significant when
performing the adjusted IRR (p = 0.011). These findings suggest that when matched for age,
gender, and BMI, runners opting for a barefoot strategy over a shod strategy were significantly
less likely to report an injury (Table 8).

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Table 8. Age-Gender-BMI Matched Analysis: Results from the (multivariate) binomial regression
analysis (excluded variables do not have enough counts to perform the analyses)
Variable Matched pairs (case=21 vs control=21)

IRR [95% CI]/p-value Adjusted IRR [95% CI]/p-
value
Barefoot
Yes#
No 5.417 [1.399 20.969]/ 0.014 10.484 [1.711 64.262]/
0.011
Duration of running
<5#
6-10 0.125 [0.012 1.333]/ 0.085 0.180 [0.014 2.336]/ 0.190
11+ 0.073 [0.007 0.712]/ 0.024 0.081 [0.006 1.144]/ 0.063
Running volume per week (days): NA
Q6
0-2# 2.062 [0.313 13.575]/ 0.451
3 0.214 [0.024 1.877]/ 0.164
4 0.600 [0.082 4.400]/ 0.615
5+
Gender NA
Male
Female 1.333 [0.360 4.933]/ 0.666
Age (years) NA
18-39
40+ 0.688 [0.190 2.486]/ 0.568
BMI NA
<25#
<30 0.545 [0.140 2.120]/ 0.382
30+ 3.273 [0.308 34.724]/ 0.325
Surgery history
No#
Yes 7.143 [0.751 67.979]/ 0.087 7.591 [0.550 104.685]/
0.130
Injury history (Q12) NA
No#
Yes 1.143 [0.273 4.786]/ 0.855
The surface that you run on with NA
more than 50%: Q9, Q35, Q36
Asphalt/Concrete#
Outdoor trail 0.882 [0.110 7.058]/ 0.906
The surface that you run on most NA
often: Q9, Q35, Q36
Asphalt/Concrete#
Outdoor trail 0.593 [0.088 4.009]/ 0.592
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How many times did you complete: NA

Q8
5K
High (>2) 1.154 [0.298 4.467]/ 0.836
Low (≤2)
10K NA
High (>1)
Low (≤1) 0.533 [0.128 2.225]/ 0.388
Half marathon NA
High (>1)
Low (≤1) 0.438 [0.092 2.083]/ 0.299
Full marathon NA
High (>0)
Low (=0) 0.893 [0.222 3.594]/ 0.873
Ultra marathon NA
High (>0)
Low (=0) 0.797 [0.154 4.130]/ 0.787
Running pace for (min/mile) NA
5K 0.902 [0.54 1.506]/ 0.692
10K 0.784 [0.475 1.294]/ 0.341 NA
Half marathon 0.886 [0.495 1.583]/ 0.682 NA
Full marathon 0.794 [0.388 1.625]/ 0.528 NA
Ultra marathon 0.797 [0.154 4.130]/ 0.787 NA
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Chapter VI: Discussion, Conclusions and Implications of research
Interpretation of Results
Running related injury is a widely researched topic, more so in the past decade with
regards to shoe type and barefoot or shod conditions, but gaps in the literature led this study to
answer the question regarding injury incidence in a running population utilizing barefoot and
shod strategies (A. Altman & Davis, 2016; Bergstra, Kluitenberg, Dekker, Bredeweg, &
Postema, 2015; Carlos et al., 2016; Davis et al., 2017; Grier et al., 2016; Hollander et al., 2017;
Kluitenberg et al., 2015; Malisoux et al., 2015; B Marti et al., 1984; Nigg, Baltich, Hoerzer, &
Enders, 2015; Oestergaard, 2015; Saragiotto, Yamato, Hespanhol, Rainbow, & Davis, 2014;
Sinclair, 2014; Videbæk & Bueno, 2015). This study found that runners implementing a
barefoot strategy were statistically less likely to report an injury as compared to runners that
choose to wear shoes (p = 0.011). Many factors and variables influence and contribute to this
finding warranting further discussion, consistent with the current literature (A. Altman & Davis,
2016; Malisoux et al., 2015). The null hypothesis, there is no statistically significant difference
in injury incidence rates between barefoot and shod runners, was rejected.
The finding that barefoot runners report fewer injures was expected. The foot
architecture and the paleontological background lend evidence to support that humans are
anatomically and physiologically designed to run long distances (Bramble & Lieberman, 2004;
Klenerman & Wood, 2006; McDougall, 2011), and as humans developed as a species this
running would have been done without shoes or with a simplistic foot covering that would mimic
the conditions of running barefoot (Gilligan, 2010; McDougall, 2011). If running barefoot was
inherently dangerous or was strongly correlated to severe musculoskeletal injury, humans would
RUNNERS 49
not have survived the evolutionary process (Bramble & Lieberman, 2004; Klenerman & Wood,
2006; McDougall, 2011).
Runners with fewer years of experience reported an increased prevalence of injury. In
the statistical analysis of this sample, specifically in the secondary analysis matching the sample
of 21 barefoot runners with 21 shod runners, those that had been running for more than 11 years
were significantly less likely to report an injury (p = 0.024) as compared to those running less
than 5 years. Runners reporting a history of running for 6 to 10 years were also less likely to
report injury as compared to those running less than 5 years (p = 0.085) which is not statistically
significant but still strongly correlated. Similar findings presented in the larger analysis of all
runners but were not statistically significant. This finding was consistent with previously
published research (Videbæk & Bueno, 2015), supporting the correlation between running
longevity and decreased injury. Paradoxically this study found that runners who self-identify as
experienced or professional runners report more injury. In the larger full sample analysis
performed (n = 545), those who identified as experienced were significantly more likely to report
injury as compared to those identifying as beginner level (p = 0.024). Those reporting being a
professional runner were also more likely to report injury as compared to beginners (p = 0.071)
demonstrating a strong correlation. Interpretation of this finding is that self-identification of
“beginner” or “experienced” level of runner may not accurately represent the duration of running
history, or relative risk of injury, without more specific operational definitions. One study
(Kluitenberg et al., 2015) found that novice runners, defined as those just beginning a running
program, were significantly more likely to sustain injury as compared to runners with any
previous experience in the sport.

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A consideration for this study is the possibility that the 21 barefoot runners had also
coincidentally been running for longer durations. The previous data and literature correlating
longer history of running experience and decreased risk of injury might confound the current
findings of the barefoot runners being at lower risk. However, there was no significant finding
that the subjects in this sample had a difference in years of experience when compared to
barefoot versus shod conditions. The runners in this sample, both barefoot and shod, had no
difference in longevity of participation in the sport. Running duration however should not be
ignored as considerations should be made for a “healthy runner effect,” which refers to runners
with longer history of running experience being inherently more capable bodies of running as a
sport therefore leading to fewer injuries over a longer period of time (Buist, Bredeweg,
Lemmink, Mechelen, & Diercks, 2010; Bernard Marti, Vader, Minder, & Abelin, 1984).
An unexpected finding of the study was the lack of statistical significance in injury
reporting as compared to weekly running volume. Previous literature (Hart & Smith, 2008;
Ramskov, Nielsen, Sørensen, Parner, & Lind, 2016; Tam et al., 2014) described running volume
as a relevant factor associated with injury risk where this study did not. One possible
explanation for the discrepancy is the type of data collected. Where previous studies had
collected data on mileage ran per week (Ramskov et al., 2016), this study surveyed subjects on
number of days per week running was performed. While both variables give insight on a
training regime, volume is best measured by mileage or time spent, while frequency is best
measured in days per week. It is clinically interesting however that no statistical difference
exists in injury risk as compared to number of days ran in a given week. Subjects reporting
running 5 or more days per week were not significantly found to be at a greater risk of injury
than runners reporting 0-2 average running days per week (p = 0.615). Missing information in
RUNNERS 51
this variable is the average length of run for each type of subject, possibly leading to the
discrepancy with the literature. Not all previous literature was consistent that running volume
was not a factor to injury risk as one study (Ramskov et al., 2018) found there to be no
significance to injury risk with comparison to running volume.
This study found no significant difference in injury risk when compared to the variable of
gender. The literature is conflicting on this topic but a majority of the literature demonstrates a
gender difference with injury risk with running (Worp, Haaf, Cingel, & De, 2015). One study
(Buist et al., 2010) found men to have significantly higher risk of injuries when compared to
women. This study found no such correlation, possibly explained by the unequal demographics
of 192 males and 353 females. While both are acceptable ranges of respondents, the inequality
of group might have influenced the findings. Gender was not reported in the secondary analysis
of the 21 runners as the group was too small to further divide in a meaningful way to show
statistical significance.
Another unexpected finding of the study was the discrepancy of injury as related to BMI.
In the original analysis of 545 runners, subjects with a BMI between 25 to 30 were found to have
a statistically lower risk of injury when compared to those with a BMI of less than 25 (p =
0.036). Those with a BMI of greater than 30 did not have a significantly higher or lower risk of
injury (p = 0.428). Expectation of this variable, based on amount of load through the body
during running, would be a higher risk of injury with a higher BMI which was not found nor
supported by the literature (Worp et al., 2015). In the matched analysis of 21 barefoot runners to
21 shod runners, BMI was not found to be a significant factor with any grouping. A systematic
review of running injuries found BMI to not be an overall factor associated with risk (Worp et
al., 2015), however one study (Wen, Puffer, & Schmalzried, 1997) found higher BMI to be a risk
RUNNERS 52
for females and lower BMI to be a risk for males with running. The unexpected significance of
decrease risk with the group of 25-30 BMI can possibly be again explained by the unequal
gender groups of the original sample that was then corrected in the secondary analysis matching
subjects for age, gender, and BMI.
Previous literature found a strong correlation between history of previous injury and risk
of sustaining another injury with runners (Worp et al., 2015). The current study found a
significant difference (p = 0.015) for risk of injury in those that had reported a previous injury.
This finding was in the original analysis including all runners. In the matched sample analysis,
this variable was surprisingly no longer significant (p = 0.855), potentially due to the smaller
sample size. Previous literature found exercise-related leg pain to be a factor associated with
injury risk (Bennett & Bennett, 2012), with compared to history of injury being a significant risk
factor in runners (Middelkoop, Kolkman, Ochten, & Koes, 2008; Wen et al., 1997).
Another unexpected finding of the study was that there was no statistically significant
difference between injury rates and the surfaces subjects reported spending the most time
running upon. There is a significant gap in the knowledge with this variable, but one study
(Bernard Marti et al., 1984) also found no correlation between running surface and injury risk.
Runners in the current study were asked what surface they ran on most often including
asphalt/concrete, outdoor trail, treadmill, and other options. The larger cohort analysis yielded
no significant difference in with injury reporting in these groups. The smaller matched sample
analysis also did not result in significant findings, and due to the smaller sample sizes, the groups
were divided into groups that responded spending more than 50% of their time on either
asphalt/concrete or outdoor trails. Again, there was no significant difference in injury reporting.
While this was not a foundational research question of this study, the findings are relevant to
RUNNERS 53
consider for the body of knowledge and future studies. It is the opinion of this author that the
running community strongly believes the running surface influences injury risk, but data does not
exist to support this belief. This study, as well as previous data (Bernard Marti et al., 1984;
Worp et al., 2015) show no such correlation. Again, the small number of barefoot runners
analyzed in this study is a limiting factor but the finding is consistent.
Another unexpected finding of this study revealed that there was no significant difference
in injury reports when compared to the fastest running pace of different lengths of races. Subjects
were asked to report their fastest recorded running pace for distances of 5k, 10k, half marathon,
full marathon, and ultramarathon in the past year. Regardless of speed reported, no significant
difference was measured in relation to injury risk. One study (Damsted, Parner, Sørensen,
Malisoux, & Nielsen, 2017) also found no relationship between running pace and injury risk.
Cadence however did seem to be a significant factor for injury risk despite the actual speed
(Schubert, Kempf, & Heiderscheit, 2014). The lower the cadence reported, the higher the rate of
injury. The authors of this 2014 systematic review concluded that higher cadence rates,
regardless of a self-selected running speed, were found to significantly reduce the number of
injuries reported. This was theorized to be found due to the decreased vertical loading forces
associated with a higher cadence (Schubert et al., 2014). The findings of the current study
support these previous findings, and future research should utilize the variable of cadence as
compared to pace or speed as a relevant factor for potential risk of injury.
Limitations
This study did have limitations that should be considered when interpreting the results.
The data was collected via survey which inherently poses risk for inaccuracy and bias from
respondents. Due to the data being self-reported, as well as retrospective, considerations should
RUNNERS 54
be made for subject’s ability, or inability, to accurately recall the information asked in the survey
as well as potential bias about their own health condition. It is possible they were not able to
fully recall the details of their past year of running experience and answered to the best of their
ability, although potentially not accurately. It is also possible that some runners have a
psychological component to answering questions about their injury history. Barefoot running as
a sport was found to be labeled as “natural” yet “extreme” in a 2016 study (Walton & French,
2016), leading this researcher to consider the type of athlete who might be attracted to running
barefoot as a preference. The possibility exists that athletes who elect to participate in a sport
with aforementioned self-description might have a bias when answering a survey about injury
that, as operationally defined, required them to take time off of their running program. If there
was a psychological or emotional attachment to a barefoot strategy, those subjects who reported
this characteristic might have been biased against admitting to injury and possibly skewing the
results.
This study also had a small sample size of barefoot runners (n = 21) that made the
statistical analysis challenging. In the original statistical analysis of the full sample, this proved
to be a significant concern between such disparate sample sizes. The secondary analysis
matching the 21 barefoot runners to 21 shod runners matched for age, BMI, and gender provided
a more accurate comparison between groups but did limit the findings due to a significantly
smaller sample size for analysis.
It should also be considered that any bias on the researchers’ part must be controlled for
to avoid inaccurate findings. In an effort to mitigate this risk, the survey was validated by
multiple outside experts as outlined previously in the field to ensure the questions were worded
in a neutral manner. It was the belief of this researcher before the initiation of this study that
RUNNERS 55
barefoot running was a safer option for running do to the architecture of the foot and the
evolutionary components of human development highlighted above. This bias however should
be acknowledged as a potential limitation of the study, despite efforts to control for error.
Recommendations for Future Research
Recommendations for future research include performing a prospective study with a
larger sample size of barefoot and shod runners over a longitudinal design. A well designed
randomized trial of novice runners would add to the body of knowledge. As reported previously,
novice runners were more likely to report injury as compared to more experienced runners, but
the question remains determining if this is a true effect or if those athletes who have been
running longer durations are more anatomically or genetically predisposed to running a sport and
report less injury subsequently. This question would be answered with a future study
randomizing a large sample of novice runners into barefoot and shod groups, followed by an
identical running program over time.
Advancement for the Field and Conclusive Summary
This study provides statistical evidence showing that runners opting for a barefoot
strategy are at a statistically significant less likelihood to report injury from their sport. The
healthcare community, as well as running athletes and their supporting coaches and team, can
utilize these findings to make more informed choices about their shoe wear choices, or the choice
to run without shoes or in a barefoot simulated type of shoe. More research is needed to
strengthen these findings on a larger scale and over time before conclusive and definitive
statements can be proclaimed, however, the findings of this research add to that body of
knowledge of injury prevention strategies in a running population. As our communities of

RUNNERS 56
athletes continue to participate in running as a sport and recreation, more must be done to
understand the risk factors associated with injury. This study contributes to that aim, providing
valuable information for those seeking data on running without injury.

RUNNERS 57
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RUNNERS 65
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Appendix A: Survey for Data Collection
Q0 You are invited to participate in a voluntary survey for research conducted by Dr.
Chad Woodard in the Ph. D. program at Trident University. The purpose of this study is to
gather information regarding the types and incidence of injuries between runners who run
with shoes and those who run barefoot. Your participation is voluntary and will only
involve completing this questionnaire. Completing the questionnaire should require less
than 10 minutes of your time. You are not required to identify yourself on the
questionnaire. The researcher will not place codes on the questionnaire that could directly
identify you. The results of this research might be published. Any research reports or
publications resulting from this research will not reveal your name or identity. Your
response to this survey is requested by March 17, 2017. Please send all questions regarding
this study to chad.woodard@touro.edu. Please only take this survey if you have
participated in running as a form of exercise in the last year.
I have read and understand the above information and (choose one):
o I agree to participate (1)

o I do not agree to participate (2)
Skip To: End of Survey If You are invited to participate in a voluntary survey for research conducted by
Dr. Chad Woodard i... = I do not agree to participate
Q41 Have you participated in running as a form of exercise in the past year?
o Yes (1)
o No (2)
Skip To: End of Survey If Have you participated in running as a form of exercise in the past year? = No
Q1 Gender
o Male (1)
o Female (2)
o Other (3)
RUNNERS 72
Q2 Age
o 18-24 (1)
o 25-29 (2)
o 30-34 (3)
o 35-39 (4)
o 40-44 (5)
o 45-49 (6)
o 50-54 (7)
o 55-59 (8)
o 60-64 (9)
o 65-69 (10)
o 70 or greater (11)
Q3 Height
0 1 2 4 5 6 7 8 10 11 12
Feet ()
Inches ()
Q4 What is your weight (lbs)?

100 130 160 190 220 250 280 300
RUNNERS 73
Weight in pounds (lbs) ()
Q5 Please indicate any known past medical history (select all that apply)
RUNNERS 74
▢ Cancer (1)
▢ Circulation issues (2)
▢ Asthma (3)
▢ Liver disease (4)
▢ Herniated disk (5)
▢ Heart condition (6)
▢ Blood clot (7)
▢ Arthritis (8)
▢ Diabetes (9)
▢ Stress fracture (10)
▢ High blood pressure (11)
▢ Thyroid dysfunction (12)
▢ Anemia (13)
▢ Hepatitis (14)
▢ Osteoporosis (15)
▢ Neurological disorder (16)
▢ Kidney disease (17)
▢ Stroke (18)
▢ Other (please specify) (19) ________________________________________________

RUNNERS 75
Q33 Have you ever had surgery for a ligament, muscle, bone, tendon, or joint injury?
o Yes (1)
o No (2)
o Unsure (4)
Display This Question:

If Have you ever had surgery for a ligament, muscle, bone, tendon, or joint injury? = Yes
RUNNERS 76
Q34 Please select the type of surgery you had:
▢ Knee joint replacement (1)
▢ Hip joint replacement (4)
▢ ACL recontruction (5)
▢ PCL reconstruction (6)
▢ Medial Meniscus surgery (7)
▢ Lateral Meniscus sugery (8)
▢ Bunion surgery (9)
▢ Achilles Tendon surgery (11)
▢ Lumbar discectomy (10)
▢ Lumbar laminectomy (14)
▢ Lumbar fusion (12)
▢ Other (please specify) (13) ________________________________________________

If Have you ever had surgery for a ligament, muscle, bone, tendon, or joint injury? = Yes
RUNNERS 77
Q43 When was the surgery?
o 0-1 years ago (1)

o 1-5 years ago (2)
o 5-10 years ago (3)
o More than 10 years ago (4)
Q38 How long have you been running as a form of exercise?
o 0-5 years (1)

o 6-10 years (2)
o 11-15 years (3)
o 16-20 years (4)
o 21-25 years (5)
o More than 25 years (6)
Page Break
RUNNERS 78
Q26 Which best describes your level of experience as a runner?
o Beginner (1)
o Somewhat experienced (2)
o Moderately experienced (3)
o Very experienced (4)
o Professional runner (competing for monetary prizes) (5)
Q32 Which of the following best describes how you run?
o I run barefoot (no shoes) (1)

o I run in barefoot-simulation shoes (ie: Vibram Five Fingers) (2)
o I run with shoes on (3)
o I run both barefoot and with shoes on at different times (4)
o I run both barefoot-simulation and with shoes on at different times (5)
RUNNERS 79

If Which of the following best describes how you run? = I run barefoot (no shoes)
Or Which of the following best describes how you run? = I run both barefoot and with shoes on at
different times
Q24 How long have you been running barefoot?
o 0-5 years (1)

o 6-10 years (2)
o 11-15 years (3)
o 16-20 years (4)
o 21-25 years (5)
If Which of the following best describes how you run? = I run in barefoot-simulation shoes (ie: Vibram
Five Fingers)
Or Which of the following best describes how you run? = I run both barefoot-simulation and with
Q25 How long have you been running with barefoot-simulation shoes?
o 0-5 years (1)

o 6-10 years (2)
o 11-15 years (3)
o 16-20 years (4)
o 21-25 years (5)
RUNNERS 80

If Which of the following best describes how you run? = I run with shoes on
different times
Q23 When running with shoes on, which of the following best describes your shoe choice?
o Minimalist shoe (least supportive) (1)

o Neutral shoe (medium level of support) (2)
o Motion control shoe (most supportive) (3)
o Unsure (4)
Q6 During the past year, how many days per week do you typically run on average?
o 0 (1)
o 1 (3)
o 2 (4)
o 3 (5)
o 4 (6)
o 5 (7)
o 6 (8)
o 7 (9)
RUNNERS 81
Q7 During the past year, how many miles per week do you typically run on average?
0 10 20 30 40 50 60 70 80 90 100
Miles per week ()

If Which of the following best describes how you run? = I run barefoot (no shoes)
different times
Q9 When you run BAREFOOT, please indicate the surface(s) that you run on. Select each
category by estimated percentage of time spent on that surface.
_______ Asphalt/Concrete (1)
_______ Outdoor trail (2)
_______ Treadmill (3)
_______ Track (4)
_______ Grass (5)
_______ Synthetic turf grass (6)

If Which of the following best describes how you run? = I run in barefoot-simulation shoes (ie: Vibram
Five Fingers)
RUNNERS 82
Q35 When you run in BAREFOOT-SIMULATION SHOES, please indicate the surface(s) that
you run on. Select each category by estimated percentage of time spent on that surface.
_______ Track (4)
_______ Grass (5)

If Which of the following best describes how you run? = I run with shoes on
different times
Q36 When you run WEARING SHOES, please indicate the surface(s) that you run on. Select
each category by estimated percentage of time spent on that surface.
_______ Track (4)
_______ Grass (5)
Q8 In the past year, how many times have you completed the following race distances?
5K : _______ (1)
10K : _______ (2)
Half Marathon : _______ (3)
Full Marathon : _______ (4)
Ultra Marathon (>26.2 miles) : _______ (6)
Total : ________
RUNNERS 83

If In the past year, how many times have you completed the following race distances? [ 5K ] >= 1
Q28 In the past year, what is your personal best running pace for a 5K distance race?
o 12:00 min/mile average or slower (1)

o 11:00 - 11:59 min/mile average (2)
o 4:59 min/mile average or faster (9)
o Unsure (10)
Page Break
RUNNERS 84

If In the past year, how many times have you completed the following race distances? [ 10K ] >= 1
Q29 In the past year, what is your personal best running pace for a 10K distance race?

o Unsure (10)
Page Break
RUNNERS 85

If In the past year, how many times have you completed the following race distances? [ Half
Marathon ] >= 1
Q30 In the past year, what is your personal best running pace for a HALF MARATHON
distance race?

o Unsure (10)
Page Break
RUNNERS 86

If In the past year, how many times have you completed the following race distances? [ Full
Marathon ] >= 1
Q31 In the past year, what is your personal best running pace for a FULL MARATHON distance
race?

o Unsure (10)
Page Break
RUNNERS 87

If In the past year, how many times have you completed the following race distances? [ Ultra
Marathon (>26.2 miles) ] >= 1
Q32 In the past year, what is your personal best running pace for an ULTRA-MARATHON
distance race?

o Unsure (10)
Page Break
RUNNERS 88
Q12 Did you have any injuries BEFORE YOU BEGAN your training? (Example: stress fracture,
rotator cuff tears, sprains, muscle strains, etc.)
o Yes (1)
o No (2)
Q13 If yes, please specify:
________________________________________________________________
Q23 In the past year, how many injuries did you have DURING training that you attribute to
running?
o 0 (1)
o 1 (2)
o 2 (3)
o 3-5 (4)
o >5 (5)
Skip To: Q14 If In the past year, how many injuries did you have DURING training that you attribute to
running? = 0
Q24 If you were injured during training, specify the cause and site of the injury.
RUNNERS 89
Overuse injuries occur over time during repeated stress, while trauma refers to injury occurring
in a single event or during an accident.
Running
Overuse (1) Trauma (2)
RUNNERS 90
Neck (1)
▢ ▢
Shoulder (2)
▢ ▢
Elbow (3)
▢ ▢
Wrist/Hand (4)
▢ ▢
Thoracic Spine (5)
▢ ▢
Lumbar Spine (6)
▢ ▢
Hip (7)
▢ ▢
Knee (8)
▢ ▢
Thigh (9)
▢ ▢
Calf (10)
▢ ▢
Ankle (11)
▢ ▢
Foot (13)
▢ ▢
Toes (14)
▢ ▢
Other (12)
▢ ▢
RUNNERS 91
Q26 Did the injury cause you to (check all that apply):
▢ Miss days of training (1)
▢ Decrease training volume (2)
▢ Seek medical attention (3)
▢ Take medication (4)
▢ Stop running completely (5)

Injury Incidence Between Barefoot and Shod Runners

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Injury Incidence Between Barefoot and Shod Runners

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INJURY INCIDENCE BETWEEN BAREFOOT AND SHOD

A Correlational Analysis of Reported Injury Incidence between

Barefoot and Shod Runners

Presented to the Dissertation Committee of the

College of Health Sciences of Trident University International

in Partial Fulfillment of the Requirements for the Degree of

Doctor of Philosophy in Health Science

(Defended June 20, 2018)

Office of Academic Affairs

Date June 20, 2018

Dean: Mickey Shachar, PhD

Director, PhD Program: Ryan Dwight, PhD

Committee Chair: Frank Gomez, PhD

Committee Member: Ralph Garcia, PT, PhD

Committee Member: Carlos Cardillo, PhD

Copyright © 2018 Chad Woodard

of injury during a running program to increase concomitantly. Recently a trend of running

and collaborating with his exceptional team of brilliant physios.

triathlons, and other extreme endurance events.

they remind me to be, and what we will become together.

me to go confidently where I needed to be without fear.

wish that I bring the same to you at every turn I take.

To my dissertation committee, I am grateful for your dedication and efforts to help me

and I am eternally grateful to him.

Table 1. Summary of biomechanics between barefoot and shod conditions

Table 2. Study variables and level of measurement

Table 8. Age-Gender-BMI Matched Analysis: Results from the (multivariate) binomial

Figure 1. Types of minimalist shoes.

Figure 2. Examples of motion control shoes.

Figure 3. Images of three different types of foot strikes with running.

Figure 5. Conceptual framework

Lieberman, 2004). These evolutionary advantages allowed humans to become uniquely

Lieberman, 2012; McDougall, 2011).

frostbite in cold climates (Davis, 2014).

1984; Robbins & Waked, 1997).

Davis, 2014; Van Gent et al., 2007).

Trends are being observed in subcultures of endurance running towards a barefoot or

lack of empirical evidence demonstrating a measurable difference between the incidence of

Chapter II: Problem Statement and Research Question

chooses a minimalist shoe as opposed to traditional shoe or barefoot, as well as considerations

with the surface on which a runner chooses to run.

RQ I: For runners, is there a significant difference in incidence of reported injury between

barefoot and shod conditions?

Chapter III: Literature Review

(a) (b) (c)

ligaments and joints (Wit, Clercq, & Aerts, 2000).

Various Footstrike Patterns and Kinematic/Biomechanical Implications

(Lieberman, 2012; Lieberman et al., 2010; Murphy et al., 2013).

proposed to decrease risk of injury in the runner (Thompson et al., 2014).

increased force in a barefoot runner.

al., 2008) theorized to potentially change incidence of injury.

Table 1. Summary of biomechanics between barefoot and shod conditions

Factor Barefoot running Shod Running

Strike Pattern Forefoot Rearfoot

Impact transient of GRF Minimal High

Loading rate 3X less than shod 3X higher than barefoot

Energy efficiency Higher Lower

Leg stiffness Lower Higher

Ankle stiffness Lower Higher

2014)(Tam et al., 2014). A meta-analysis of thirteen studies on running efficiency between

This increased efficiency as measured by oxygen consumption can be attributed to decreased

further study to adequately demonstrate improved energy efficiency in a barefoot running

population (Cheung & Ngai, 2014).