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What are the benefits and risks associated with changing foot strike pattern during running? A systematic review and meta‑analysis of injury, running economy, and biomechanics

Review written by Tom Goom info

Key Points

  1. There is limited evidence of lower injury rate in runners with a non-rearfoot strike pattern.
  2. Transitioning from a rearfoot strike to a non-rearfoot strike does not appear to be beneficial for running economy and may result in a short-term decrease in economy.
  3. A non-rearfoot strike may reduce load at the knee but appears to increase it in the calf and Achilles.

BACKGROUND & OBJECTIVE

Foot strike is a controversial and sometimes divisive issue in the running community. Many believe that a forefoot strike is ‘natural’, more efficient and less likely to lead to injury. Despite these beliefs being often strong held, there is little quality evidence to support them. This systematic review sought to synthesize the research on the differences between foot strike patterns and how this relates to injury, running economy and biomechanics.

There is little quality evidence to support the belief that a forefoot strike is ‘natural’, more efficient and less likely to lead to injury.
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Clinicians should approach the topic of gait changes not with the assumption that one specific way is best, but instead with the question in mind – Does this change help achieve my patient’s goals?

METHODS

A comprehensive search strategy of key research databases was used based on Cochrane Collaboration guidelines. Studies were included if they compared rearfoot strike (RFS) and non-rearfoot strike (NRFS) patterns while running. Studies included comparison of habitual and imposed foot strike patterns as well as different surfaces (treadmill, overground etc) and different footwear conditions (shod, barefoot etc). Case reports, non-English studies, small trials (less than 10 subjects per cohort), gait retraining studies and running on uneven surfaces (such as downhill) were excluded. PRISMA guidelines were followed and study quality was appraised. Data was carefully analyzed and pooled for meta-analysis.

RESULTS

A total of 53 studies were included in the review. Quality appraisal found 16 to be high quality, 35 moderate quality and 2 were low quality.

Injury

One high-quality study provided limited evidence that runners with a habitual NRFS pattern had a significantly lower rate of injury compared to habitual RFS. However, this study was limited by its retrospective design.

Running economy There was conflicting evidence of differences in running economy between habitual RFS and NRFS. There was moderate evidence that running economy decreased when runners transitioned from habitual RFS to an imposed NRFS at a medium speed. There was also limited evidence of a decrease in economy at slow speed but no change in economy at a fast speed, and limited evidence of no difference in running economy at the end of long run (at medium speed). When habitual NRFS runners changed to RFS, limited evidence indicated no change in economy at slow, medium and fast speeds.

Biomechanical findings

Imposed NRFS led to greater ankle plantar-flexion at foot strike and reduced vertical loading rates. Many findings were inconsistent when assessing an imposed NRFS, but there was evidence of reduced knee flexion range and knee load in NRFS alongside increased gastrocnemius muscle activation and Achilles tendon load (an additional 48 times body weight for each mile run).

Some parameters differed between runners with habitual RFS and those with NRFS, but no difference was evident when a NRFS was imposed on habitual RFS runners. These parameters included stance contact time (shorter in habitual NRFS) and peak hip adduction (reduced in NRFS, but limited evidence). This suggests some aspects may require a period of habituation or that an imposed NRFS is not identical to a habitual one.

There was no difference in 8 out of 10 hip and trunk variables when comparing RFS and NRFS, suggesting strike pattern may have little effect on proximal biomechanics.

The authors concluded - “Considering the lack of evidence to support any improvements in running economy, combined with the associated shift in loading profile, changing strike pattern cannot be recommended for an uninjured RFS runner”.

LIMITATIONS

  • Studies that used gait re-training or changed footwear were excluded so the results from this paper apply only to trying to change foot strike.
  • Only 1 included study attempted to blind assessors and only 1 reported adverse events.
  • Study designs and definitions of NRFS varied (some included both midfoot and forefoot strike under NRFS).
  • Most studies included in the meta-analysis evaluated asymptomatic populations.

CLINICAL IMPLICATIONS

A key learning point from this review is to approach gait changes not with the assumption that one specific way is best, but instead to ask if this change achieves an athlete’s goals. Forefoot striking has long been advocated as the ‘best’ way to run or as ‘proper’ running form despite the lack of evidence to support this. This view has led to many runners being encouraged to transition to this foot strike under the assumption that it’s best for all. Unfortunately for some this has led to injury, lost training time and impaired performance.

Common goals for changing running gait are improving efficiency and reducing injury risk. This review highlights that there is limited evidence that a non-rearfoot strike pattern has a lower rate of injury and recent research found injury rates were not significantly different between those that transitioned to NRFS and those that remained as RFS (1). Running economy actually decreased following transition to NRFS in some studies within this review, and there were no studies to identify the long-term effects of such a transition.

It is difficult to draw conclusions from this review on the role of changing foot strike in injured runners as most studies within this meta-analysis were on asymptomatic populations. Clinicians should be mindful that while a NRFS may reduce load on the knee, it does appear to increase it on the calf and Achilles. Transition to forefoot strike has been found to reduce patellofemoral pain in a small RCT (2), but 25% of subjects developed ankle pain. Increasing step rate by 10% has also been found to be effective in runners with patellofemoral pain (3) but without the disadvantage of increasing load significantly at the foot and ankle.

+STUDY REFERENCE

Image [Anderson L, Bonanno D, Hart H and Barton C (2019) What are the Benefits and Risks Associated with Changing Foot Strike Pattern During Running? A Systematic Review and Meta-analysis of Injury, Running Economy, and Biomechanics. Sports Medicine.]()

SUPPORTING REFERENCE

  1. Morris, J., Goss, D., Miller, E. and Davis, I. (2019). Using real‐time biofeedback to alter running biomechanics: A randomized controlled trial. Translational Sports Medicine.
  2. Roper, J., Harding, E., Doerfler, D., Dexter, J., Kravitz, L., Dufek, J. and Mermier, C. (2016). The effects of gait retraining in runners with patellofemoral pain: A randomized trial. Clinical Biomechanics, 35, pp.14-22.
  3. Bramah, C., Preece, S., Gill, N. and Herrington, L. (2019). A 10% Increase in Step Rate Improves Running Kinematics and Clinical Outcomes in Runners With Patellofemoral Pain at 4 Weeks and 3 Months. The American Journal of Sports Medicine, 47(14), pp.3406-3413.
  4. Almonroeder, T., Willson, J. and Kernozek, T. (2013). The Effect of Foot Strike Pattern on Achilles Tendon Load During Running. Annals of Biomedical Engineering, 41(8), pp.1758-1766.