Today on the Doc On The Run podcast we’re talking about the differences between minimalist and maximalist running shoes.
Minimalist running shoes, maximalist running shoes and barefoot running, they’re all some of the more recent trends in running and running shoe technology. There’s a lot of debate around these different kinds of running shoes as well as different running forms and I was recently invited to give a lecture at the International Foot and Ankle Foundation meeting in Lake Tahoe on February 17, 2017.
This is a medical conference that’s given to podiatrists and sports medicine doctors, foot and ankle surgeons, all to learn about different trend and new treatments for their patients. I was invited to give a lecture entitled “Minimalist vs. Maximalist running current trends” and in that talk I was going to try to explain to doctors the difference is really between minimalist is versus maximalist running shoes because many doctors don’t even understand the differences between these shoes and I think that you as a runner can actually learn from the differences and understand that there’s some big miss around both of these different types of running shoes and the running form that may be associated with them and it may help you understand how to prevent injury and run further with less stress and hopefully without as much risk of injury.
The first thing you have to know is that for a long time conventional running shoes we basically had a few choices. Initially when the Nike waffle trainer came out and that was a new type of running shoe the basically had an elevated heel that was just made to show that there’s a difference really between a completely flat running shoe and one with an elevated heel. But in recent years when doctors have given patients choices of running shoes, they really talk about one of three things either a cushioning shoe or a stability shoe and then a few variations in between. So really, we’ve talked about three basic classes of running shoes.
When you think about the three different classes of running shoes, there’s basically three different types. There’s a neutral running shoe which is basically built for somebody with lots of inherent stability in the foot and high arches who kind of has impact as an issue. Then at the other end of the spectrum is motion control shoes which are those for people with instability in the foot which are people with flat foot deformity and issues like that and then there’s in between is sort of this slight stability or what we call structured cushioning choice and those are really the three broad choices. So when they say, “What kind of shoes should I use?” most doctors including myself many years ago, I would actually give a sheet of paper to the patients that a have a list of running shoes that divided them up in one of those three groups.
For people with really high arches, who were prone to stress fractures and those types of issues, I would give them a handout that showed the different types of running shoes and I would circle a big neutral running shoe section and say “You should get these” or if they had really flat feet and instability in their foot then I would say, “Well you should probably get motion control shoes”.
Now when you think about conventional running shoes we talk about with their construction. We say, “Okay, well conventional running shoe basically has a heel height that’s roughly ten to twelve millimeters tall or higher than the forefoot”. So when you hear the term “drop of a shoe” it’s referring to the difference in height between the heel and the forefoot and so a conventional running shoe has a drop of about ten to twelve millimeters.
Conventional running shoe also have EVA or Ethylene-vinyl acetate midsole cushioning material which is supposed to cushion you from the stress of running and they’re usually made up of multiple layers of material. There’s a hard outsole, there’s EVA cushion in the midsole then there’s what we called medial posting or adding material to the inside arch area of the shoe that adds support and based on the heel counter and all these other different construction materials. There can be lots of support or a little support based on the way she was built and that’s the standard way that conventional running shoes have been built for many years.
Minimalist shoes
Minimalist shoes are different. Rather than having a ten to twelve millimeter dropped shoe, they’re either zero drop. Meaning no lift in heel at all where they’re very low drop, just a few millimeters. They also have lots of torsional flexibility. You can twist them back and forth, twist them out of shape. They’re very lightweight because they don’t have lots of external medial posting and all these other different construction materials that make them more stable and they have a minimum midsole with very little cushioning and as a consequence of all these things they have very little support.
A maximalist shoe is different. So the Hoka was the first real maximalist shoe that came out and many people think of maximalist shoes as being the polar opposite of a minimalist shoe and that’s not really true. A maximalist shoe does have more cushioning and it looks much bigger and thicker and it looks completely different than a minimalist shoe. But it’s not actually the polar opposite of that. So in my mind when somebody says “Aren’t maximalist shoes really the other end of the spectrum from a minimalist shoe?” my answer is really NO.
The polar opposite of a true minimalist shoe is actually a conventional running shoe that’s made for people with stability issues, a motion control shoes like the Brooks Beast. Something that’s very heavy, very stable, lots of medial posting, lots of inherent stability in the foot. That is really the polar opposite of a minimalist shoe.
Now maximalist shoes, interestingly have some of the same exact functions, construction and intentions as minimalist shoes. Many of them in fact actually have a low drop heel. So even though the sole looks very thick because it’s made of this sort of very light blown EVA foam in the midsole and the sole may be very thick. The actual drop of the shoe is usually pretty small. It’s usually somewhere between two and six millimeters in terms of the drop. 
They’re relatively lightweight given their size. So even though they look really big when you pick up as you like a Hoka, when you pick it up it’s actually surprisingly lightweight given how big it looks. They also, because the soles are often flared outward, they have a relatively supportive wide stance.
The minimalist shoes again, they’re no cushion, no stability. They’re really designed for barefoot or natural running form which lets the body supposedly mitigate forces and if you run with a true forefoot of midfoot strike that may be true. Maximalist shoes, they have lots of cushion. They have lots of external shock absorption and they have some external stability but they primarily want to let the shoe mitigate the forces in a sort of protected way that you would use the same kind of form that you would use with a barefoot running technique but it’s a little bit more protective.
Now let’s step back for a second when we think about minimalist versus maximalist. A lot of doctors say that maximalist trend came about as a consequence of people getting injured too much with barefoot running or minimalist shoes and when you think about that you think why would people want to run barefoot anyway. Well one of the reasons is that if there is some evidence that it can be more efficient. If it’s a more efficient running form, it’s not complicated. It takes less energy. You can one further, you can run faster because you’re running more efficiently. Running barefoot can also help you improve your form if you follow some basic principles and some guidelines. There are lots of people that argue that improving your form can make you more efficient. There are some people that believe running with a minimalist style or running barefoot could actually decrease your risk of injury even though the APMA disagrees with that and has a position statement that says that “that’s really not a good idea”. And many people like to run barefoot simply because the way that it feels more natural. They feel more in contact with the ground and they just like experience of it.
This is not a new trend. Even though people say it’s a brand-new trend, it’s really not. Zola Budd ran in 1984, was famous for running barefoot. Unfortunately she had an incident where she tripped another runner accidentally and was sort of heavily reprimanded for that. Abebe Bikila also from Rome 1960 Olympics, he actually set a world record 2:15:16.2. I mean 2:15 is fine no matter how you cut it. Even today, 2:15’s pretty fast and he ran barefoot. So it’s not new at all, I mean that was fifty years ago when he ran the marathon barefoot
In 2009 though, Born to Run came out and in this book, Christopher McDougall argues pretty convincingly that running shoes themselves, conventional running shoes seem to contribute in some ways to running injuries and he discusses this concept of running with the barefoot style that can be more efficient decreased risk of injury and so that sort of set off as explosion of minimalist running.
The thing is, the big debate is does forefoot running, forefoot strike, midfoot strike, is it more efficient or not and the shoes really protect you from the pounding or do they cause an unnatural sort of pounding form just because you’re wearing the shoes. We don’t really have a true answer to that but the American Podiatric Medical Association came out in 2009 with a position statement that said basically barefoot running can lead to injuries such as puncture wounds and increased stress on lower extremity. But the fact is, there’s no actual research that shows that so although I am a podiatrist and I’ve been a member of the American Podiatric Medical Association disagree with the position statement in many ways. I agree with in some ways if you run barefoot in the grass at the Golden Gate Park and you step on some piece of glass, a syringe that somebody left in the grass or a rock or something like that. You can certainly get a puncture, you could get an injury but there’s no proof. There’s no actual evidence that shows that running barefoot will lead to injuries. That’s just not true.
My disagreement with the American Podiatric Medical Association position statement is that I don’t really think you can say don’t run barefoot or use minimalist forms because there’s no proof that it can keep you safe. But instead use conventional running shoes because there’s actually no evidence that conventional running shoes reduce the risk of injury. Now there’s an interesting guy named Barefoot Bob but he’s been run a long time and he says a lot of things that make sense to me. He says running barefoot is probably not for everyone. Only for people who were born with senses in bare feet and he also says if you want an expert opinion about running barefoot, don’t ask the man behind the curtain selling shoes or orthotics supports because obviously people have their motivations and so podiatrists selling orthotics that are very very expensive and trying to convince everybody they need them. It’s probably not going to sell you a barefoot running idea because they cannot sell you orthotics. That does not mean that most podiatrists are doing that. It’s just that it’s an interesting take that Barefoot Bob has on that. But again you have to think what everybody’s motivation is.
There’s lots of research that’s been done on barefoot running and one of the things that was really interesting was this graph that came out. It was published in Nature back in 2010 and it basically showed that if you’re running and landing as a heel striker, there’s this moment of impact that produces this real serious point or spike on a force curve that can be delivering too much shock to your system. And then if you’re running barefoot, you get a much smoother ground reactive force curve which is the amount of impact spread out over a longer period of time and that sort of the graph that seems to be used as evidence by the barefoot running community that there’s a much lower risk of injury.
Now it makes sense. The interesting thing is that when you look at the comparisons of a foot striking force and loading rates, it’s seven times lower. When you’re landing as of a barefoot forefoot striker versus a barefoot heel striker, seven times lower force. That’s a huge difference in force but it’s roughly equivalent if you’re running barefoot landing on your forefoot. It’s roughly equivalent to running and pushing conventional running shoes, landing as a heel striker.
Although there’s all this of stuff about maybe being more efficient like there’s a study that showed oxygen consumption was about 4-5% lower in barefoot running and that actually if included factor in the shoes weight. Obviously because shoes weight something so if you’re picking them up and putting them down, that uses energy but they factor that out and it was still 4-5% lower oxygen consumption which implies that it’s more efficient.
We also know that energy demand increases about 1% for every 100 grams of additional mass on the shoes. The lighter the shoes, obviously better. Although there’s been some research, it’s not really that convincing. There was some interesting research that came out and the journal of a sports medicine and health science, a medical journal in 2014 that showed that if runners were instructed on how to run and attempt to land as a forefoot or midfoot striker that they could actually gradually reduce and lower that initial spike from heel striking. Which implies it can reduce the force because it smooths out the curve.
Again, although there’s been some research in medical literature about barefoot running, it’s not really proof that you can run safer, longer without running shoes. That you can run safer barefoot. As a personal antidote on my end, I had a tried Newton’s. I was asked to write a review for them many years ago when they came out and I’d always been a relatively slow 4-hour marathoner and I would do marathon, 4 hours. Not run for a month and then go run 4 hours and when I used the Newton’s. I actually use them just for speed work. I used them only on my mile repeat days on the track once a week and all I did was I would run in the Newton’s, focusing on landing is a forefoot midfoot striker trying to maintain an upright posture. Trying to maintain a slight vertical lean at the angles, not at the hips and then I would focus on cadence and all I would do is do my mile repeats. Focusing on those issues with form and staying exactly on pace.
The next marathon I ran, I was 20 minutes faster, ran 3:40 and no matter how you cut it, that’s a huge chop of time and now these days I can do Ironman marathon, get off the bike after 112 miles and still run under 4 hours. So it’s been a huge improvement for me and part of it is that the Newton’s, I don’t think they’re magical but they really do help you learn very quickly about your running form. Because the lugs that protrude under there show you the wear pattern and they’re very easy to analyze and determine where you’re really landing when you’re trying to learn how to be more forefoot, midfoot striker.
If you’re running barefoot, running surface really matters and here in San Francisco you have lots of choices. So if you run around, you can run on the asphalt jogging path or you can run on this sort of crushed granite stuff next to the jogging path. If you run at the path of the ocean beach, you have this asphalt jogging path you can run on or you can also run on the sort of sandy packed trail part on the side of the track there. You can also in Golden Gate Park you have lots of choices. You can run in the road on the asphalt. You can run on one side of the street, there’s usually dirt path and on the opposite side of the street there’s a paved path. So you can run in a variety of different locations even here in San Francisco and these locations are all in a couple of miles of each other.
Wherever you live, it’s important to make sure you have the right choice. Now I often see patients that say they got injured with barefoot running and they’ll say that they’re running on the dirt path because they think it would be more forgiving and then they get to this section where the dirt path goes from the slightly higher elevation basically goes slight downhill for about two miles and this one area, it’s eroded and there are large rocks protruding from the dirt path and their big and some of them the size of bricks and I’ve seen patients that roll their ankles there. I’ve seen patients that have gotten stress fractures there. A variety of different kinds of tendonitis, plantar plate tears, all sorts of things from landing on these obstacles in the paths. So it’s not rocket science, you need to not step on sharp objects or protruding rocks when you’re running no matter what kind of shoes you’re using but some errors are worse than others. The path is pretty stable in most places but there where it runs downhill and the running water from the rain has it eroded that can be very irregular.
We know that the trends in running shoes are often sort of the sales basically is used as a marker of how popular a kind of running shoe is or a trend and minimalist running shoes were really ramping up 2009, 2010, 2011 and the last few years. And then Hoka also have been really increasing in sales. They had around 2 million dollars in sales in 2012 but then they went up to like 8.8 million I think in 2015, above the prior year. So they’re really ramping up in sales and Hoka’s growing very rapidly and though shoes really are taking on a huge amount of the in the market share by comparison to where they were when they first got started.
Minimalist shoes, one thing you have to be cautious of is that many patients that I see don’t even know they’re running on minimalist shoes. I was actually going to give a lecture on a medical conference in Seattle one time and on the plane I was reading a triathlon magazine. I had this issue of the triathlete magazine and it had an article. It was the 2013’s best new models of shoes and they had 16 running shoes. In review of those running shoes, only three of them which were two zero drop shoes and one three millimeter drop shoe, only three of those 16 shoes did they say actually were minimalist shoes. The other 13, they basically reviewed them but they didn’t say anything about them being minimalist shoes even though I would really categorize seven of those, half of them basically as minimalist shoes. So runners that got those shoes may not actually be fully aware that they’re running minimalist shoes.
There are also lots and lots of books on natural running or minimalist running, Born to Run is probably one. They’re recommend by physicians the most just because that someone’s been read but it seems like most patients who take up minimalist running. But there are lots of other good books. Chi running is a great book. Pose Method of Running is a great book. Danny Abshire’s Natural Running which helps people learn how to run with more minimalist form.
But the modern running shoe has all been built on this idea of supporting and protecting the runner or attempting to support and protect the runner with an elevated heel and cushioning in the midsole. The minimalist shoes are way less cushioning. They’re way less protective and they have a thin outsole. One of the things that I think is really interesting is that barefoot Bob, one of things he says that really makes sense to me is he says that barefoot shoes, minimalist shoes should be there to protect experienced barefoot runners and he sort of argues with which really make sense is if you run truly barefoot, you cannot run far enough to injure yourself or get a musculoskeletal injury like stress fracture tendonitis because the skin on the bottom of your feet isn’t tough enough to take it.
He’s been running for many years barefoot successfully. He’s written a book on running barefoot and he understands it and I think that what a lot of what he says make sense. Even though lots of podiatrists want to discount what he has to say. I really agree a lot with many of the things barefoot Bob says and this idea that if you run barefoot. I mean I can run 20 miles today for sure no problem but if I took off my shoes and took off down the street, I don’t think I’d make it 2 miles. In fact, I actually found a post on someone’s blog where he went and ran barefoot. I think after about a mile, he had all these abrasions where it took the skin right off his toes and that would be true for most runners. But most experienced runners really can run a long way if they start running in minimalist shoes because they’re protected. Their skins protected as they can get these injuries.
We know that Vibrams had actually settled the lawsuit made in 2014. It was 3.75 million dollar lawsuit. Basically they had all this kind of advertising without proof. They were saying that these shoes would strengthen muscles on the feet and legs, improve range of motion, stimulate the neural function that could help you balance agility and all this other stuff. There was no real proof of that and so there was a lawsuit and people that bought those shoes actually got some money back. It was said that they could get up to $94 per paid but in actuality most probably end up getting somewhere $20and $50 fifty dollars per pair.
But the point is, is that there was no proof that that actually works, that it actually did what they claimed. Shortly thereafter, right after that lawsuit there was an article in the lower extremity review which is basically a magazine that’s sent out to mostly podiatrists, sports medicine doctors and physical therapists that was entitled The Rise and Fall of Minimalist Footwear where they said that basically this is dead that this whole idea of minimalist running is over. I don’t believe that’s true.
One thing that’s really interesting, Irene Davis said that you have to fortify system and you can’t just suddenly load it. That’s really what barefoot Bob is saying and she says if you do it slowly enough your body will adapt. We just don’t know how slow is slow enough really and that’s really barefoot Bob’s argument. He agrees with this professor at Harvard. They basically say a similar thing and that if you load your system slow enough, you can adapt to running barefoot. Then you’re really not going to run that far because it’s going to hurt your skin. Your skin limitation is going to slow you down. Hopefully enough that you can ramp up and not have injuries to your musculoskeletal system.
When people ask me, doctors at conferences, who should not run barefoot? Well that’s simple. Some people with documented osteoporosis or who seem to be at high risk of osteoporosis, who have weak bones are more likely to get stress fractures and I think they’re more likely to get injured. If they have a history or posterior tibial tendonitis, I think they’re more likely to get injured because everything’s two wobbly, too unstable. If they have sesamoiditis, sesamoid injuries or injuries to the two little bones underneath the big toe joint and there’s pain under the big toe joint. I think that’s very risky to run barefoot because you’re landing right on those. Also, I think the people who gets sesamoiditis in minimalist shoes sometimes it’s not because the way they’re landing. I think that’s a misconception. I think that sometimes people get sesamoiditis from minimalist shoes because they’re simply so unstable that they’re pronating or rolling across the sesamoid and sort of pinching the inside tibial sesamoid bone and it’s causing irritation of that little bone underneath there. I think that people with Achilles tendinopathy, Achilles tendonitis, peritonitis. Any sort of problem with the Achilles tendon. I think it’s very high-risk. I also don’t think that at risk diabetics. People who can’t really feel their feet. They definitely should not be running barefoot.
What I tell runners if they want to try running they should do it really really gradually. They should ideally run barefoot either on a track, some place in the grass that’s safe and free of obstacles or on the beach, on the hard packed sand on the apron of the beach and I like to think of it as a cross training tool. I run in 4 different types of shoes depending upon what kinds of workouts I’m doing and then I think it’s really important to analyze the wear patterns on the bottom of the shoe and adjust your stride accordingly so that you can improve your form and make sure you’re not landing too far forward.
When people start this, I give them a very specific schedule and it’s really slow. The first time they run one mile, only one mile. Yes I know you’re thinking I would never run a mile but one mile is what I think is best and no back-to-back runs in your minimalist shoes when you’re doing that. I think it’s important to ramp up and see how your body’s responding.
Now shifting back to the maximalist shoes. So Hoka’s were really the first maximalist shoes and it’s a really really interesting story because these two guys Nico and Jean-Luc are two French guys that both work together at Salomon and they worked on all different kinds of stuff. But it’s a really fascinating story because it seems like what they’re trying to do is not really come up with a maximalist shoe necessarily but they were looking for a way to increase cushioning downhill runs. They had this sort of idea that they could make an outsole or an external shoe that could cover an existing running shoe that could use them for increased cushion on that severe pounding when somebody runs down the side of a mountain. And this idea of a maximalist running shoe kind of comes from a number different things including oversized mountain bike tires, oversized tennis rackets and so they kind of drawn their experience of shaped skis and started shaping the EVA soles rather than adding tons of extra material for stability.
They experimented with the materials and getting the EVA fluffier and sort of more expansive so that it was bigger and lighter and that what they came up with was the first Hoka and it had twenty nine millimeters of cushion. So it’s a big thick sole but it was all shaped. It was very very lightweight by comparison. Maximalist shoes, it’s not just more cushion. Everybody thinks it’s more cushion, more material and all that but it’s not. So there is this low drop minimalist shoe, when you think about maximalist shoe you think about that concept that low drop minimalist shoe with that idea that can encourage midfoot or forefoot strike, well Jim Van Dine at Hoka says we agree with that geometry but we provided in a protected environment rather than the unprotected environment that Vibrams did.
It’s not completely different but there are some unique features built into the Hoka’s. One of them is an oversized midsole. Obviously it’s much thicker than a regular shoe but it has this rocker. A curvature that’s built into the forefoot and that rocker is fairly stiff. So when you pick up a Hoka, it’s big and it’s light but then when you try to twist it or you try to bend the forefoot, it’s actually pretty stiff. Part of that is because of this unique active foot frame that they have built into the sole itself.
Hoka Bondi
Hoka’s come in a variety of different styles now. They have lots of them and there have been lots of copiers. There are lots of people that imitate the Hoka’s and there’s the Altra, have a zero drop maximalist shoe but has a 36 millimeter outsole. So it’s a very thick sole but is zero drop. So there’s no heel lift at all. So again, this Olympus that Altra makes is really, it’s similar in some respects to a minimalist shoe but it has a lot more cushion, a lot more padding to protect you.
We think that minimalist shoes can teach you how to use your body to cushion the impact. But Irene Davis once said that maximalist shoes don’t really teach you how to do that. So if the cushioning wears out after two or three hundred miles or some chance that you might start getting aches and pains because you’re no longer protected because the EVA will collapse over time.
When we think about this we think “Okay well that makes sense. You’re protected, you’re cushioned. Does that really mean you reduced risk of injury”? Well, we don’t really know that but what we do know is that there’s a study in 2010 comparing running on pavement to running on grass and it found that softer surfaces lead to lower localized pressure on the bottom of the foot. No surprise because you’re spreading that forces because you’re landing on something softer. But of course, the overall sum of forces isn’t any higher. The cushion just spreads it out.
A 2013 study that showed runners transitioning to minimalist shoes showed an increase in bone stress injury, as measured by MRI, when compared to runners using traditional shoes and so maybe the opposite is true as well. How is that? One thing is that if you’re landing on the softer surface then your body has to do something to add stability and part of that is increasing leg stiffness.
There was a study in 2007 that demonstrated that runners with a history of tibial stress fractures or stress fractures in the shin bone may have higher leg stiffness at the knee joint when they run. The higher the leg stiffness, that stiffness may transfer more of the shock to the skeletal system and increase your risk of an injury.
Running on ultra-soft surfaces requires leg stiffness and we think that could contribute to some of these other kinds of stress injuries but we don’t know that for a fact. There’s some very new research coming out that shows that there’s some interesting biomechanics that are kind of at play when people are running in highly cushioned running shoes. That’s all in the very early stages yet, there’s no real evidence that maximalist shoes can protect you and Jim Van Dine at Hoka in an interview that I heard of him recently on Runners Connect which is very interesting interview by the way, here’s the link. Jim Van Dine says when asked about evidence, he said “We’re very careful to say that there is no evidence right now and obviously with what Vibrams went through, the last thing that Hoka wants is to be accused of making false claims”.
So they are very good at making shoes that protect and stabilize the foot but whether or not that means that they’re going to be injury-free, we certainly cannot say that. But it is an interesting concept and again it’s not the exact opposite of minimalist shoes. It’s just, it’s a more protective way of running with minimalist form potentially with lower risk of injury but studies will show that eventually.
There are lots of people that do recommend Hoka’s for when they get injured. One of them is for sesamoiditis. There are many people that I think can benefit from those shoes. It’s just trying to figure out whether or not your particular running form, your biomechanics and your history of injury really warrants the shift in your shoes. So when you go to the running shoe store and you’re trying to determine whether or not you should try a minimalist shoe or maximalist shoes or some version of a conventional running shoe, you have to go in with the knowledge of what your history has been, what kind of injuries you get and then talk to the experts, the running shoe store and try to get them to help you understand which shoe might be best for you for which reason and that’s regardless of what the current trends are.
If you have a question that you would like answered as a future addition of the Doc On The Run Podcast, send it to me PodcastQuestion@docontherun.com. And then make sure you join me for the next edition of the Doc On The Run Podcast!
Dr. Christopher Segler is a podiatrist and ankle surgeon who has won an award for his research on diagnosing subtle fractures involving the ankle that are often intially thought to be only ankle sprains. He believes that it is important to see the very best ankle sprain doctor in San Francisco that you can find. Fortunately, San Francisco has many of the best ankle sprain specialists in the United States practicing right here in the Bay Area. He offers house calls for those with ankle injuries who have a tough time getting to a podiatry office. You can reach him directly at (415) 308-0833.
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