How to Evaluate and Recommend Athletic Shoes
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C U RRE N T TO P I C S I N S P O RTS P O D I ATRY
How to Evaluate and
Recommend Athletic Shoes
AAPSM reviews the latest in athletic footwear.
By Karen A. Langone, DPM
This article is provided exclusively
to Podiatry Management by the Ameri-
can Academy of Podiatric Sports
Medicine. The AAPSM serves to ad-
vance the understanding, prevention
and management of lower extremity
sports and fitness injuries. The Acade-
my believes that providing such knowl-
edge to the profession and the public
will optimize enjoyment and safe par-
ticipation in sports and fitness activi-
ties. The Academy accomplishes this
mission through professional educa-
tion, scientific research, public aware- more biomechanical con-
ness and membership support. For ad- trol and biomechanical cor-
ditional information on becoming a rection, to companies de-
member of the AAPSM please visit our signing minimalist shoes,
website at www.aapsm.org or circle to recommendations from
#151 on the reader service card. some quarters that runners
Figure 1: Shoe components should simply go barefoot.
A
thletic shoe technology is It is important to keep in
an ever-changing entity. Re- biomechanically, anatomically, and mind that competing ideas create
cent technological alter- sport-appropriate. improved footwear. We can surely
ations to running shoes are the re- The American Academy of Podi- provide technological information
sult of extensive research and dif- atric Sports Medicine (AAPSM) uti- to our patients, but the real art of
fering views about what is best for lizes a four-point system, both to making recommendations lies in
runners and athletes. Athletic shoes combining that information with
are as diverse as the people who use an understanding of each individu-
them; therefore, it is vital to under- al patient’s unique needs and cir-
stand the differences between the cumstances. AAPSM’s four-point
various types of shoes, such as system consists of reviewing the lit-
those with cushioning, stability, erature, reviewing foot function, re-
motion control, and the numerous viewing footwear construction, and
models that are available. It is also then looking at footwear function
imperative for the podiatric physi- as an evaluative process.
cian to be aware of current trends Patients often ask, what is the
in running shoes, including toning study and then allow us to recom- best running shoe for me? The an-
shoes, barefoot running, and mini- mend shoes to our patients. The swer to that question is as diverse as
malist running technology. Our need for evaluation is crucial, now the patient population. It is impor-
goal as sports medicine podiatrists more than ever as we find ourselves tant to keep in mind that for every
is to advise our patients as to the having to choose among many dif- foot there is a shoe. Through the
athletic shoe that will allow them ferent competing concepts and years, we have seen multiple tech-
maximum performance with mini- technologies—from companies nologies; some stay and some go. We
mal risk of injury and that is also moving to create shoes with ever- Continued on page 108
www.podiatrym.com OCTOBER 2010 • PODIATRY MANAGEMENT 107
Athletic Shoes... fort. He also stated that footwear en- increased impact forces due to the
hances performance through in- shoe bottoming out when loaded,
remember Easy Coil shoes, the creasing traction and biomechanical and that firmer shoes were more
Reebok Pump and Earth shoes as efficiency, and that footwear can preferential as they did not bottom
trends that vanished with time. How- also reduce injuries by correcting for out. However, in 1987, they also
ever, there are patients who liked the locomotor system static struc- showed that cushioning can reduce
those shoes and felt that they im- tural misalignments. He goes on to impact forces, and the geometry of
proved their individual conditions. say that footwear protects the foot at shoes can affect pronation in rear-
In reviewing the research, Mario the interphase with the ground and foot strikers. Nigg further postulat-
Lafortune from the Nike Sport Re- the entire body against the forces re- ed in the 2001 article in the Clinical
search Laboratory published an arti- sulting from repeated foot ground Journal of Sports Medicine that the
cle in September 2008 in Journal of impacts. Running shoe cushioning runner reacts to the combined con-
Foot and Ankle Research in which he has proven to be both beneficial and ditions of a shoe sole orthotic or in-
postulated that the three main detrimental to runners. sert cushioning and plantar recep-
needs of the athlete are perfor- In 1981, Nigg, et al. showed tive surface, and accordingly ad-
mance, injury protection, and com- that shoes with more cushioning justs muscle activity, fatigue, com-
fort, work, and per-
formance.
Additional re-
TABLE ONE search suggests that
cushioning in run-
AAPSM's 2010 Running Shoe Guide ning shoes can
cause excessive sub-
talar joint motion
MAXIMUM STABILITY
(Clement, et al.,
Asics Gel-Evolution 5 New Balance 1012 1981). A 1992 arti-
Asics Gel-Foundation 8 New Balance 587 cle in the American
Asics Gel-Fortitude New Balance 1123 Journal of Sports
Brooks Beast Nike Zoom Nucleus MC+ Medicine by
Brooks Ariel (women) Nike Zoom Equalon+3 Dressendorfer, et al.
Brooks Addiction 8 Saucony ProGrid Stabil CS showed that reticu-
Mizuno Wave Renegade 4 locytosis of the
rearfoot was in-
creased markedly in
STABILITY runners who ran
with a firm shoe
Adidas Mizuno Wave Inspire 6
versus those with a
Adidas Supernova Sequence Mizuno Wave Elixir 4
Asics Gel-3010 New Balance 760 more cushioned
Asics Gel-Kayano 16 New Balance 850 shoe, and that ery-
Asics GT -2150 New Balance 993 thropoietic activity
Asics Gel-1150 New Balance 1225 was positively cor-
Asics Gel-DS Trainer 15 Nike Structure Triax+ 12 related with peak
Brooks Adrenaline GTS 10 Nike Lunarglide+ G-forces. Finally,
Brooks Infiniti 2 Nike Air Span+ 6 Lieberman, et al. in
Brooks Switch 3 Nike Zoom Elite+ 4 Nature in January
Brooks Ravenna Saucony Progrid Omni 8 2010 looked at five
Brooks Trance 9 Saucony ProGrid Hurricaine 11
groups of runners
Mizuno Wave Alchemy 9 Saucony ProGrid Guide 3
and found that
forefoot barefoot
NEUTRAL strikers generated
the lowest impact
Adidas Adistar Ride Mizuno Wave Rider 13 forces versus shod
Adidas Supernova Glide Mizuno Wave Precision 10 runners and bare-
Adidas Response Cushion New Balance 1064 foot runners who
Asics Gel-Nimbus 11 New Balance 883 were rearfoot strik-
Asics Gel-Kushon 2 New Balance 905
ers. However, for
Asics Gel-Cumulus Nike Air Pegasus+ 26
Asics Gel-Landreth Nike Air Max Moto+7 rearfoot strikers,
Brooks Glycerin 8 Nike Zoom Vomero+ 4 running shod pro-
Brooks Defyance 3 Reebok Premier Verona KFS II duced lower impact
Brooks Ghost 2 Saucony ProGrid C2 Glide forces than running
Mizuno Creation 11 Saucony ProGrid Jazz 13 barefoot. So, we are
left with conflicting
Continued on page 110
108 PODIATRY MANAGEMENT • OCTOBER 2010 www.podiatrym.com
Athletic Shoes...
research to date as to both the ben-
efits of cushioning and various
footstrike patterns and the forces
correlated with each.
Foot Function
The next component in evaluat-
ing what shoe is best for the patient
is looking at the patient’s foot func-
tion. Evaluating foot function is
certainly a complicated arena to
enter. Although we have classically
been instructed in the rigid high
arch foot, the “normal arch,” and
the low arch flexible foot, we all
know that there is a greater contin-
uum that exists with some patients Figure 2: Somnio customizable components
having a high arch flexible foot and
other patients having a low arched fit in shoes to their longest toe, op- sive review of shoe construction,
rigid foot. Often, patients are told timally having a thumb’s width in describing the outsole upper and
to evaluate their foot type by using space beyond the end of the mid-sole. The mid-sole lies between
the “wet paper test.” In this test, longest toe to the tip of the shoe. the upper and the outsole and is
the patient wets the foot and then Running shoe companies and usually composed of EVA or TPU.
stands on a piece of paper and eval- running magazines use extensive The mid-sole is the most important
uates the foot type that appears. sophisticated testing processes both part of the shoe in terms of cush-
Minimal foot contact is indicative in the development and then in ioning and stability, and it deter-
of the high arched foot, moderate the evaluation of the performance mines the cushioning and stability
foot contact a normal arch, and full characteristics of the shoe, as well
contact is indicative of a low arch. as the shoe’s functionality. Manu-
Again, this evaluative process is facturers use their proprietary cush-
flawed as it does not allow for pa- AAPSM’s four-point ioning systems within the mid-sole
tients who fit outside these three foam. Most commonly, encapsulat-
classic presentations and does not system consists of ed air gel or other materials are
in any way take into account the found in shoes such as the Nike Air,
rigid flexible foot or the inflexible
reviewing the Asics Gel, Saucony Grid, Brooks
flatfoot. This is where the expertise literature, reviewing DNA, etc. To date, there has been
of the podiatric physician comes in no research which has shown the
and our ability to evaluate each foot function, superiority of one type of material
foot type. It is important to know versus another.
reviewing footwear
the foot type of the patient in order
to match it with the best type of construction, and then Medial Post
shoe for the patient. Classically Another important component
speaking, the rigid high arched foot looking at footwear of the shoe is the medial post. This
is going to go into a cushioned is the firmer component within the
function as an mid-sole and is usually comprised
neutral-type shoe, the normal
arched patient is going to do best evaluative process. of a dual density EVA and can also
in a stability shoe, and the flexible contain TPU, which is thermoplas-
pes planus foot type is going to do tic urethane or carbon fiber. The
best in a more stable shoe. function of the medial post is to de-
of their shoes. Classically, flexion termine the stability of the shoe,
Shoe Fit tests are done determining the flex- and the medial post dampens or
Fit is also a major consideration. ibility of the shoe in the forefoot decreases the speed of pronation.
Certain manufacturers make shoes and how smoothly it transitions Medial posts are found in all stabili-
with widths that will better accom- from heel strike to toe-off. An im- ty and motion-controlled shoes,
modate a wider foot structure; pact testing is done to evaluate the but are generally not found in
some running and athletic shoes firmness of the shoes mid-sole. cushioned or neutral shoes. Their
are constructed with deeper and Testing is also performed to evalu- benefit is to provide stability, but
higher toeboxes, which will better ate the wear of the shoe and to de- they do add weight to the shoe.
accommodate patients with ham- termine how long it will hold up The shank of the shoe stiffens the
mertoe deformities. Fit in length is under use. On the Academy shoe under the arch area. Most run-
also important. Patients should be (AAPSM) website, we do an exten- Continued on page 112
110 PODIATRY MANAGEMENT • OCTOBER 2010 www.podiatrym.com
Athletic Shoes... ed, slip-lasted, and combination-
lasted, as well as Strobel, which is
ning shoes, except the most flexi- now the most common type of last
ble, incorporate a shank which is construction utilized. In the Stro-
usually constructed of urethane. bel-lasted shoe, a thin sheet of ma-
terial or EVA is glued to the mid-
Shoe Last sole, and the upper is stitched to
The shoe last—the model over this. It is identified by stitching
which the foot is constructed—de- around the perimeter of the foot
scribes the shape of the shoe. Last bed, and it is a hybrid of the last
shapes include curved, semi-curved, types (Figure 1).
and straight. Curve-lasted shoes are The significance of shoe con-
lighter, more cushioned, and offer struction is that mid-sole cushion-
minimal resistance to pronation. ing stability devices, the last, and
These are commonly found in rac- even the fit all add up to determine
ing flats, competition spikes, and how much stability the shoe pro-
cushioned and neutral shoes. On vides. This is essential in our ability
the opposite end of the spectrum to evaluate an athletic shoe and to
are straight-last shoes which, as determine the type of shoe based
their name indicates, are straight. Figure 3: Newton shoes on the characteristics of its con-
They resist pronation to a greater struction. This allows us to evaluate
degree, are heavier, bulkier, and the curve-lasted. This last is typical- a shoe that the patient presents
generally also incorporate a con- ly found in most running shoes. with, and therefore aid us in deter-
trolling medial post. Straight-last The last also refers to how the mining if that shoe is appropriate
shoes are found almost exclusively upper is attached to the mid-sole. for the patient.
in motion-control shoes. A semi- The construction method utilized
curved last is a hybrid of the two: here influences the stability, stiff- Function
less controlling than the straight- ness, and flexibility of the shoe. The AAPSM fourth evaluated
lasted, but more controlling than Most common types are board-last- Continued on page 113
112 PODIATRY MANAGEMENT • OCTOBER 2010 www.podiatrym.com
Athletic Shoes... pronation resistance—and they are that we see today is towards bare-
heavier and stiffer. Stability shoes foot and minimalist running. In
step is to look at the function of are a hybrid containing semi- the category of semi-customization
the footwear. Footwear is classified curved lasts; some have medial is the Somnio running shoe. Som-
as maximum stability/motion con- posts and shanks. Neu- nios were tested at the Boulder
trol, which then can be broken tral/cushioned shoes have no medi- Center of Sports Medicine and con-
down into maximum, moderate, al post, are curve-lasted, have mini- tain various design components
and minimal; stability; neu- mal pronation resistance, and are that allow semi-customization in
tral/cushioned; minimalist and biomechanical correction. A shoe
barefoot. Each shoe company gen- retailer must be qualified in order
erates a “footwear comparison” to utilize the technology necessary
chart for each season in which they to evaluate a runner for Somnios.
list their shoe models versus their Markers are placed upon the
competitors’ correspondingly classi- runner’s feet, legs, and hips. The
fied shoe models. This footwear runner utilizes a treadmill, and a
comparison chart can be obtained computer evaluates various angles
by contacting any of the manufac- to determine how much biome-
turers. The AAPSM web site also chanical correction this runner
provides information as to shoe needs. The technician then utilizes
Figure 4: MBT rocker sole shoe
model classification (those list- this information to choose from
ings—for maximum stabili- three full-foot varus wedges that are
ty/motion control shoes, stability light and flexible. available, each with a different
shoes, and neutral cushion shoes— An interesting phenomenon in amount of correction built in, three
are listed here in Table One). The shoe design is that manufacturers foot beds each with different arch
most popular shoes are stability are moving on the one hand to- heights, and cushioning inserts at
shoes. Characteristics of the maxi- wards more high-tech, more biome- the first MTPJ and the heel. Somnio
mum stability/motion control shoe chanical correction in the shoe attempts to customize shoes based
are the largest, densest medial post, with semi-customization and com- on the functional needs of the indi-
straightest last, and maximum puter feedback, but the major trend Continued on page 114
www.podiatrym.com OCTOBER 2010 • PODIATRY MANAGEMENT 113
Athletic Shoes... Unstable Shoes mentally friendly. Brooks has devel-
The unstable shoe category, oped the Mogo mid-sole. Tradition-
vidual (Figure 2). made popular by MBT shoes, al mid-soles can last up to 1,000
Another shoe technology that Reebok, and Skechers, is another years in landfill. This new material
has gained popularity is the New- trend in athletic will change that
ton shoe. The Newton shoe was de- shoes. This tech- 1,000 years to 20
signed specifically for mid- to fore- nology was devel- years, therefore
foot strikers and actually contains oped based on making it more
what are termed actuator lugs, the Masai, an environmentally
which are raised rubber rectangles African tribe, and friendly.
located in the forefoot of the shoe. how they walk in Born to Run
At contact, the lugs are pushed into the sand. These by Christopher
the mid-sole, where they stretch a unstable shoes are McDougall sug-
membrane. At push-off, the mem- also termed ton- gests that run-
brane rebounds and the actuators ing shoes. The ning long dis-
are pushed from the mid-sole back theory behind tances barefoot is
to the outsole, returning energy them is that they the key to happi-
into the forward propulsion (Figure turn our flat hard ness and longevi-
3). Another shoe built along this artificial surface ty. McDougall
similar philosophy is the Karhu, into a natural un- proposes that the
which encourages minimal heel even ground, elaborate archi-
contact time and embraces a ful- similar to walk- Figure 5: Nike Free tecture and cush-
crum technology to return energy ing in sand. Due ioning of shoes is
to the runner. to this change in function, these a cause of athletic injury. Mc-
The pose run- shoes challenge Dougall bases this conclusion on
ning method de- the core strength- his observations of the Tarahu-
veloped by ening muscles to mara, a tribe noted for their ability
Nicholas Ro- Patients should be more active. to run extreme distances in diffi-
manov, a Russian This changed cult environmental conditions
Ph.D., has been be fit in shoes to muscle action with relatively little injury. Born to
advocated by its then creates good Run has created a devoted group of
proponents to de-
their longest toe, posture, and in- runners who have adopted this
crease injury optimally having a creases shock ab- barefoot running trend, either in-
rates in runners. sorption for the corporating it as part of their rou-
This is a move- thumb’s width in joints, while sig- tine, or moving to training entirely
ment method space beyond the end nificantly reduc- this way. The book is a vivid tale,
based on main- ing musculoskele- but does take dramatic literary li-
taining a particu- of the longest toe to tal compression. cense in its interpretation of the
lar strike and This technology events that are portrayed. It has
body position the tip of the shoe. appears to be very been, however, a best selling book
where the runner similar to the and has generated an entire tech-
lands on the ball rockerbottom nology behind it.
of the foot, keeps technology used Keep in mind that once one
the foot in an initial position and by pedorthists and podiatrists, but places any type of material upon
does not push off, but rather pulls this new technol- the foot, one is
the foot off the ground using the ogy is more ag- no longer run-
hamstring and allowing gravity to gressive than ning barefoot.
be the primary force in moving the those previous Research suggests The Nike Free was
body forward. Romanov postulates corrections were. one of the first
that it is the heel strike, present in The lack of mid- that cushioning shoes developed
most runners, which is the cause of and forefoot mo- to address the
most running injuries, and propos- tion in toning
in running shoes needs of runners
es his alternative method as a solu- shoes may help can cause excessive who wished to
tion to these injuries. The use of patients with run with minimal
the Newton and Karhu shoe fits mid-foot and subtalar joint support and cush-
into this philosophy. Again, re- forefoot com- ioning, with just
search is conflicting in this matter. plaints, but one
motion. a protective cov-
Multiple studies have shown no must be cautious ering for the foot.
metabolic or functional advantages in placing a pa- The Free was de-
for a runner who attempts to tient in such an unstable shoe (Fig- veloped with an extremely unique
switch foot strike pattern. Gruber, ure 4). design, incorporating Sipes trans-
et al. in 2009 in ACSM noted no There are even shoes now that verse fissures in the sole, which was
difference in oxygen cost. are purported to be more environ- Continued on page 115
114 PODIATRY MANAGEMENT • OCTOBER 2010 www.podiatrym.com
Athletic Shoes... of thoroughly evaluating the pa- Med. Sci. in Sports & Exercise (1987):
tient’s anatomy, function, and in- 294-302.
adapted from tire technology. This jury history cannot be overstated. Nigg, B.M., Bahlsen, H.A., Luethi,
allows the entire shoe to roll up Knowledge and staying abreast of S.M. and Stokes, S. The influence of
running velocity and midsole hardness
upon itself, so that there is very lit- current shoes and current tech-
on external impact forces in heel-toe
tle support that comes from the nologies is essential for the sports running. J. Biomechanics (1987): 951-
shoe. The shoe has what Nike terms medicine podiatrist. Even if one 959.
a better anatomical shape design does not have an extensive sports Clement D.B., Taunton, J.E., Smart
and is extremely medicine prac- G.W. & McNicol, K.L. A survey of some
lightweight as the tice, one will not overuse running injuries. Phys
mid-sole and the be able to get SportsMedicine (1981) :77-8.
outsole are the through a day at Dressendorfer, et al. “Effect of Shoe
same material, a
The significance the office without Cushioning on the Development of
phylon rubber Reticulocytosis in Distance Runners.”
of shoe construction encountering
American Journal of Sports Medicine
blend. In addition some or all of
is that mid-sole (1992): 212-16.
to the Free, Nike these shoe issues. Lieberman, et al. “Foot Strike Pat-
has developed the For patients
Glide, in which it
cushioning stability who wish to in-
terns and Collision Forces in Habitually
Barefoot Versus Shod Runners.” Nature
incorporates 2 de- devices, the last, corporate unsta- (2010): 531-35.
grees of varus cor- ble shoes or bare- McDougall, Christopher. Born to
rection in the and even the fit foot running into Run: a Hidden Tribe, Superathletes, and
shoe (Figure 5). their workout the Greatest Race the World Has Never
all add up to Seen. New York: Alfred A. Knopf, 2009.
Ecco has also schedule, it is best
come out with determine how to always ap- Hamill, et al. “Lower Extremity Stiff-
ness in Runners with Different Foot
the Biom, which proach this as
is more shoe than much stability one would ap-
Types.” J Biomech. (2000).
Grube, et al. “Metabolic Cost Of Al-
the Nike Free, but the shoe provides. proach a new tering Foot Strike Patterns In Running.”
still attempts to training activity Medicine & Science in Sports &
adhere to this or training regi- Medicine 41.5 (2009): 512.
barefoot philoso- men, with the Gruber, et al. “Segment Coordina-
phy. The shoe gradual introduc- tion Response to Alterations in Foot
most similar to actually being bare- tion of the new entity and constant Strike Pattern.” American Society of
foot is the Vibram 5 Fingers shoe, monitoring should any problems Biomechanics (2009). Web. 8 May 2010.
basically a rubber protective cover- arise. This will allow the patient to .
ing with individual toe structure. best adapt to new techniques and
Miller, et al. “Foot-Strike Pattern Se-
This seems similar in many ways to to identify any problems that may lection to Minimize Muscle Energy Ex-
an Aqua shoe in terms of the pro- occur. penditure During Running: A Computer
tectiveness that it provides to the The American Academy of Podi- Simulation Study.” American Society of
foot. The more hardcore barefoot atric Sports Medicine website and Biomechanics (2009). Web. 8 May 2010.
running proponents tend to utilize running shoe page can also help < http://www.asbweb.org/con-
this running shoe as it does most one in day-to-day practice by pro- f e r ences/2009/pdf/922.pdf.>
closely mimic the barefoot condi- viding the most current up-to-date
tion while providing a protective information on shoe technology
covering for the foot. and shoe models. Armed with this Dr. Langone is a
knowledge, we are best able to help graduate of the
Summary our patients make their healthiest New York Col-
In summary, advising patients choices. ■ lege of Podiatric
Medicine. She is
as to shoe choices is an art. Tech-
a Fellow, Ameri-
nology is constantly evolving, con- Bibliography can College of
stantly improving, and constantly Nigg, BM. “The Role of Impact Foot and Ankle
changing. Frequent research de- Forces and Foot Pronation.” Clin J Orthopedics and
bates each new technique and Sports Med (2002): 57-59. Medicine and
technology. Running shoe compa- Lafortune, Mario. “The Role of Re- Fellow, Ameri-
nies are constantly seeking new search in the Development of Athletic can Academy of Podiatric Sports
and better ways to address the Footwear.” Journal of Foot and Ankle Medicine. Dr. Langone is President of
needs of the runner, whether that Research (2008). the AAPSM. She is also Lead Clinical Di-
be for greater injury protection, Nigg, B.M., Denoth, J., and rector in New York State for Fit Feet, a
Neukomm, P.A. Quantifying the load podiatric screening service offered in
lighter, more comfortable shoes, or
on the human body: problems and connection with the Healthy Athletes®
new trends that appear. It is a com- some possible solutions. Biomechanics initiative which provides health screen-
bination of all these approaches VII (1981): 88-99. ings free of charge at Special Olympics
and philosophies that can help Nigg, B.M. and Morlock, M. The in- competitions. Dr. Langone is also a
guide us as to what is best for our fluence of lateral heel flare of running member of the AAPPM. She is in private
athletic patients. The importance shoes on pronation and impact forces. practice in Southampton, NY.
www.podiatrym.com OCTOBER 2010 • PODIATRY MANAGEMENT 115
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