Does Foot Strike Pattern Affect Injury Rates in Runners?

Printed with permission from the Cooper Institute.

Anyone that has ran for any period of time will likely be faced with a running injury as studies of distance runners report injury rates of 30-75% per year.2,3 Attempts by shoe manufacturers to design better shoes have not significantly decreased injury rates over the last 30 years.1 Many factors can contribute to the risk of injury including prior injuries, gender, body weight, flexibility, shoes, core strength, and training frequency and intensity.1 Another factor which may impact risk of injury is foot strike pattern. There are three general patterns of foot strike:

  • rearfoot strike where the heel contacts the ground first,
  • forefoot strike where the ball of the foot contacts the ground followed by the heel,
  • midfoot strike where the ball of the foot and heel contact the ground at the same time.

Rearfoot strikers typically land on the heel with the knee extended and foot contacting the ground in front of the knee and hip. This creates a rapid, high impact force. In contrast, forefoot runners land with more knee bend and the foot is more pointed (plantar flexed). In runners with forefoot landing patterns, peak impact forces are not as high as in rearfoot strikers. Midfoot strikers show less predictable landing patterns than the other strike patterns.

Barefoot runners and those wearing racing flats on hard surfaces tend to use a forefoot landing pattern. Runners that typically run in training shoes but are asked to run barefoot also adopt a more forefoot landing style. The absence of shoe heel cushioning to absorb impact forces may explain this change in landing style. The forefoot pattern is also more common at faster running speeds. For this reason, scientists think that before running shoes were invented humans may have utilized a forefoot landing pattern. This pattern may be better suited to reduce landing impact forces when running barefooted or in uncushioned shoes like sandals or moccasins. Therefore, the body may be better suited to using a forefoot landing pattern. Although some running coaches recommend runners adopt a forefoot pattern, scientific data to support this is lacking.

A recent study1 published ahead of print in Medicine and Science in Sports and Exercise examined the effect of foot strike pattern on injury rates in cross country runners. Researchers studied the number and types of running injuries associated with the different footstrike patterns. Rearfoot strikers would be expected to experience more repetitive types of injuries to the knee, hip and low back, as well as plantar fasciitis and stress fractures of the lower leg due to the higher peak landing forces. Forefoot runners would be expected to have more foot injuries, Achilles tendinitis and stress fractures in the foot.

Adam Daoud and his colleagues1 studied 52 experienced, collegiate middle and long distance cross country runners over a 4.5 year period. The runners followed similar training programs which were developed by one coach. During this time they raced on the track and natural surfaces like grass and dirt. A video camera was used to determine the primary foot strike pattern used by each runner. Researchers also measured the number, type and severity of injuries during that period.

Researchers reported that 69% of runners were rearfoot strikers and 31% were forefoot strikers. Male and female runners averaged 45 and 40 miles per week, respectively. Approximately 75% of runners reported at least one moderate or severe injury per year. Rearfoot strikers were twice as likely to have a moderate or severe injury compared to forefoot strikers. There were more injuries in females than males. Not surprising, rearfoot strikers had two to four times more repetitive types of injuries including hip, knee and low back injuries, plantar fasciitis and lower leg stress fractures compared to forefoot strikers. The incidence of injuries to the Achilles tendon and foot and stress fractures which was predicted to be higher in forefoot strikers was not different between the two groups.

It is important to remember that other factors such as speed, running surface, fatigue, body weight, type of shoe can also affect impact landing forces and risk of injury. However, this study does suggest that adoption of a forefoot strike pattern may yield lower injury rates. More research is needed to determine if changing footstrike pattern changes injury rate. There is always some concern about changing self-selected running styles. For example, a forefoot landing pattern requires stronger calf and foot muscles and could lead to Achilles tendinitis, plantar fasciitis, calf strains, foot pain and stress fractures of the foot in a rearfoot striker whose foot is not accustomed to forefoot running.

If you are currently a rearfoot striker experiencing a high rate of injury, it is a good idea to check with your doctor or physical therapist before switching to a forefoot running pattern. The lower injury rate in forefoot strikers sounds promising but needs more research. Let us know if you have changed your footstrike pattern and if that has affected your injury rate.

1Daoud, A.I., Geissler, G.J., Wang, F. et al. (2011). Foot Strike and Injury Rates in Endurance Runners: A Retrospective Study. Medicine and Science in Sports & Exercise. Published ahead of print.doi:10.1249/MSS.0b013e3182465115

2van Gent R.M., Siem D., Van Middlekoop, M. et al. (2007). Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. British Journal of Sports Medicine. 41, 469-479.

3van Mechelen, E. Running injuries. (1992). A review of the epidemiological literature. Sports Medicine. 14, 320-335.

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