biomechanically, anatomically, andsport-appropriate.

The American Academy of Podi-atric Sports Medicine (AAPSM) uti-lizes a four-point system, both to

study and then allow us to recom-mend shoes to our patients. Theneed for evaluation is crucial, nowmore than ever as we find ourselveshaving to choose among many dif-ferent competing concepts andtechnologies—from companiesmoving to create shoes with ever-

This article is provided exclusivelyto Podiatry Management by the Ameri-can Academy of Podiatric SportsMedicine. The AAPSM serves to ad-vance the understanding, preventionand management of lower extremitysports and fitness injuries. The Acade-my believes that providing such knowl-edge to the profession and the publicwill optimize enjoyment and safe par-ticipation in sports and fitness activi-ties. The Academy accomplishes thismission through professional educa-tion, scientific research, public aware-ness and membership support. For ad-ditional information on becoming amember of the AAPSM please visit ourwebsite at www.aapsm.org or circle#151 on the reader service card.

Athletic shoe technology isan ever-changing entity. Re-cent technological alter-

ations to running shoes are the re-sult of extensive research and dif-fering views about what is best forrunners and athletes. Athletic shoesare as diverse as the people who usethem; therefore, it is vital to under-stand the differences between thevarious types of shoes, such asthose with cushioning, stability,motion control, and the numerousmodels that are available. It is alsoimperative for the podiatric physi-cian to be aware of current trendsin running shoes, including toningshoes, barefoot running, and mini-malist running technology. Ourgoal as sports medicine podiatristsis to advise our patients as to theathletic shoe that will allow themmaximum performance with mini-mal risk of injury and that is also

more biomechanical con-trol and biomechanical cor-rection, to companies de-signing minimalist shoes,to recommendations fromsome quarters that runnersshould simply go barefoot.It is important to keep in

mind that competing ideas createimproved footwear. We can surelyprovide technological informationto our patients, but the real art ofmaking recommendations lies incombining that information withan understanding of each individu-al patient’s unique needs and cir-cumstances. AAPSM’s four-pointsystem consists of reviewing the lit-erature, reviewing foot function, re-viewing footwear construction, andthen looking at footwear functionas an evaluative process.

Patients often ask, what is thebest running shoe for me? The an-swer to that question is as diverse asthe patient population. It is impor-tant to keep in mind that for everyfoot there is a shoe. Through theyears, we have seen multiple tech-nologies; some stay and some go. We

By Karen A. Langone, DPM

Continued on page 108

AAPSM reviews the latest in athletic footwear.

OCTOBER 2010 • PODIATRY MANAGEMENTwww.podiatrym.com 107

C U R R E N T T O P I C S I N S P O R T S P O D I A T R Y

How to Evaluate andRecommend Athletic Shoes

Figure 1: Shoe components

fort. He also stated that footwear en-hances performance through in-creasing traction and biomechanicalefficiency, and that footwear canalso reduce injuries by correcting forthe locomotor system static struc-tural misalignments. He goes on tosay that footwear protects the foot atthe interphase with the ground andthe entire body against the forces re-sulting from repeated foot groundimpacts. Running shoe cushioninghas proven to be both beneficial anddetrimental to runners.

In 1981, Nigg, et al. showedthat shoes with more cushioning

remember Easy Coil shoes, theReebok Pump and Earth shoes astrends that vanished with time. How-ever, there are patients who likedthose shoes and felt that they im-proved their individual conditions.

In reviewing the research, MarioLafortune from the Nike Sport Re-search Laboratory published an arti-cle in September 2008 in Journal ofFoot and Ankle Research in which hepostulated that the three mainneeds of the athlete are perfor-mance, injury protection, and com-

increased impact forces due to theshoe bottoming out when loaded,and that firmer shoes were morepreferential as they did not bottomout. However, in 1987, they alsoshowed that cushioning can reduceimpact forces, and the geometry ofshoes can affect pronation in rear-foot strikers. Nigg further postulat-ed in the 2001 article in the ClinicalJournal of Sports Medicine that therunner reacts to the combined con-ditions of a shoe sole orthotic or in-sert cushioning and plantar recep-tive surface, and accordingly ad-justs muscle activity, fatigue, com-

fort, work, and per-formance.

Additional re-search suggests thatcushioning in run-ning shoes cancause excessive sub-talar joint motion(Clement, et al.,1981). A 1992 arti-cle in the AmericanJournal of SportsMedicine byDressendorfer, et al.showed that reticu-locytosis of therearfoot was in-creased markedly inrunners who ranwith a firm shoeversus those with amore cushionedshoe, and that ery-thropoietic activitywas positively cor-related with peakG-forces. Finally,Lieberman, et al. inNature in January2010 looked at fivegroups of runnersand found thatforefoot barefootstrikers generatedthe lowest impactforces versus shodrunners and bare-foot runners whowere rearfoot strik-ers. However, forrearfoot strikers,running shod pro-duced lower impactforces than runningbarefoot. So, we areleft with conflicting

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108 www.podiatrym.comPODIATRY MANAGEMENT • OCTOBER 2010

TABLE ONE

AAPSM's 2010 Running Shoe Guide

MAXIMUM STABILITY

Asics Gel-Evolution 5Asics Gel-Foundation 8Asics Gel-FortitudeBrooks BeastBrooks Ariel (women)Brooks Addiction 8Mizuno Wave Renegade 4

STABILITY

AdidasAdidas Supernova SequenceAsics Gel-3010Asics Gel-Kayano 16Asics GT -2150Asics Gel-1150Asics Gel-DS Trainer 15Brooks Adrenaline GTS 10Brooks Infiniti 2Brooks Switch 3Brooks RavennaBrooks Trance 9Mizuno Wave Alchemy 9

NEUTRAL

Adidas Adistar RideAdidas Supernova GlideAdidas Response CushionAsics Gel-Nimbus 11Asics Gel-Kushon 2Asics Gel-CumulusAsics Gel-LandrethBrooks Glycerin 8Brooks Defyance 3Brooks Ghost 2Mizuno Creation 11

Mizuno Wave Rider 13Mizuno Wave Precision 10New Balance 1064New Balance 883New Balance 905Nike Air Pegasus+ 26Nike Air Max Moto+7Nike Zoom Vomero+ 4Reebok Premier Verona KFS IISaucony ProGrid C2 GlideSaucony ProGrid Jazz 13

New Balance 1012New Balance 587New Balance 1123Nike Zoom Nucleus MC+Nike Zoom Equalon+3Saucony ProGrid Stabil CS

Mizuno Wave Inspire 6Mizuno Wave Elixir 4New Balance 760New Balance 850New Balance 993New Balance 1225Nike Structure Triax+ 12Nike Lunarglide+Nike Air Span+ 6Nike Zoom Elite+ 4Saucony Progrid Omni 8Saucony ProGrid Hurricaine 11Saucony ProGrid Guide 3

Continued on page 110

fit in shoes to their longest toe, op-timally having a thumb’s width inspace beyond the end of thelongest toe to the tip of the shoe.

Running shoe companies andrunning magazines use extensivesophisticated testing processes bothin the development and then inthe evaluation of the performance

of their shoes. Classically, flexiontests are done determining the flex-ibility of the shoe in the forefootand how smoothly it transitionsfrom heel strike to toe-off. An im-pact testing is done to evaluate thefirmness of the shoes mid-sole.Testing is also performed to evalu-ate the wear of the shoe and to de-termine how long it will hold upunder use. On the Academy(AAPSM) website, we do an exten-

research to date as to both the ben-efits of cushioning and variousfootstrike patterns and the forcescorrelated with each.

Foot FunctionThe next component in evaluat-

ing what shoe is best for the patientis looking at the patient’s foot func-tion. Evaluating foot function iscertainly a complicated arena toenter. Although we have classicallybeen instructed in the rigid higharch foot, the “normal arch,” andthe low arch flexible foot, we allknow that there is a greater contin-uum that exists with some patientshaving a high arch flexible foot andother patients having a low archedrigid foot. Often, patients are toldto evaluate their foot type by usingthe “wet paper test.” In this test,the patient wets the foot and thenstands on a piece of paper and eval-uates the foot type that appears.Minimal foot contact is indicativeof the high arched foot, moderatefoot contact a normal arch, and fullcontact is indicative of a low arch.

Again, this evaluative process isflawed as it does not allow for pa-tients who fit outside these threeclassic presentations and does notin any way take into account therigid flexible foot or the inflexibleflatfoot. This is where the expertiseof the podiatric physician comes inand our ability to evaluate eachfoot type. It is important to knowthe foot type of the patient in orderto match it with the best type ofshoe for the patient. Classicallyspeaking, the rigid high arched footis going to go into a cushionedneutral-type shoe, the normalarched patient is going to do bestin a stability shoe, and the flexiblepes planus foot type is going to dobest in a more stable shoe.

Shoe FitFit is also a major consideration.

Certain manufacturers make shoeswith widths that will better accom-modate a wider foot structure;some running and athletic shoesare constructed with deeper andhigher toeboxes, which will betteraccommodate patients with ham-mertoe deformities. Fit in length isalso important. Patients should be

sive review of shoe construction,describing the outsole upper andmid-sole. The mid-sole lies betweenthe upper and the outsole and isusually composed of EVA or TPU.The mid-sole is the most importantpart of the shoe in terms of cush-ioning and stability, and it deter-mines the cushioning and stabilitycharacteristics of the shoe, as wellas the shoe’s functionality. Manu-facturers use their proprietary cush-ioning systems within the mid-solefoam. Most commonly, encapsulat-ed air gel or other materials arefound in shoes such as the Nike Air,Asics Gel, Saucony Grid, BrooksDNA, etc. To date, there has beenno research which has shown thesuperiority of one type of materialversus another.

Medial PostAnother important component

of the shoe is the medial post. Thisis the firmer component within themid-sole and is usually comprisedof a dual density EVA and can alsocontain TPU, which is thermoplas-tic urethane or carbon fiber. Thefunction of the medial post is to de-termine the stability of the shoe,and the medial post dampens ordecreases the speed of pronation.Medial posts are found in all stabili-ty and motion-controlled shoes,but are generally not found incushioned or neutral shoes. Theirbenefit is to provide stability, butthey do add weight to the shoe.The shank of the shoe stiffens theshoe under the arch area. Most run-

Athletic Shoes...

Continued on page 112

110 www.podiatrym.comPODIATRY MANAGEMENT • OCTOBER 2010

AAPSM’s four-point

system consists of

reviewing the

literature, reviewing

foot function,

reviewing footwear

construction, and then

looking at footwear

function as an

evaluative process.

Figure 2: Somnio customizable components

the curve-lasted. This last is typical-ly found in most running shoes.

The last also refers to how theupper is attached to the mid-sole.The construction method utilizedhere influences the stability, stiff-ness, and flexibility of the shoe.Most common types are board-last-

ning shoes, except the most flexi-ble, incorporate a shank which isusually constructed of urethane.

Shoe LastThe shoe last—the model over

which the foot is constructed—de-scribes the shape of the shoe. Lastshapes include curved, semi-curved,and straight. Curve-lasted shoes arelighter, more cushioned, and offerminimal resistance to pronation.These are commonly found in rac-ing flats, competition spikes, andcushioned and neutral shoes. Onthe opposite end of the spectrumare straight-last shoes which, astheir name indicates, are straight.They resist pronation to a greaterdegree, are heavier, bulkier, andgenerally also incorporate a con-trolling medial post. Straight-lastshoes are found almost exclusivelyin motion-control shoes. A semi-curved last is a hybrid of the two:less controlling than the straight-lasted, but more controlling than

ed, slip-lasted, and combination-lasted, as well as Strobel, which isnow the most common type of lastconstruction utilized. In the Stro-bel-lasted shoe, a thin sheet of ma-terial or EVA is glued to the mid-sole, and the upper is stitched tothis. It is identified by stitchingaround the perimeter of the footbed, and it is a hybrid of the lasttypes (Figure 1).

The significance of shoe con-struction is that mid-sole cushion-ing stability devices, the last, andeven the fit all add up to determinehow much stability the shoe pro-vides. This is essential in our abilityto evaluate an athletic shoe and todetermine the type of shoe basedon the characteristics of its con-struction. This allows us to evaluatea shoe that the patient presentswith, and therefore aid us in deter-mining if that shoe is appropriatefor the patient.

FunctionThe AAPSM fourth evaluated

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Figure 3: Newton shoes

OCTOBER 2010 • PODIATRY MANAGEMENTwww.podiatrym.com 113

pronation resistance—and they areheavier and stiffer. Stability shoesare a hybrid containing semi-curved lasts; some have medialposts and shanks. Neu-tral/cushioned shoes have no medi-al post, are curve-lasted, have mini-mal pronation resistance, and are

light and flexible.An interesting phenomenon in

shoe design is that manufacturersare moving on the one hand to-wards more high-tech, more biome-chanical correction in the shoewith semi-customization and com-puter feedback, but the major trend

step is to look at the function ofthe footwear. Footwear is classifiedas maximum stability/motion con-trol, which then can be brokendown into maximum, moderate,and minimal; stability; neu-tral/cushioned; minimalist andbarefoot. Each shoe company gen-erates a “footwear comparison”chart for each season in which theylist their shoe models versus theircompetitors’ correspondingly classi-fied shoe models. This footwearcomparison chart can be obtainedby contacting any of the manufac-turers. The AAPSM web site alsoprovides information as to shoemodel classification (those list-ings—for maximum stabili-ty/motion control shoes, stabilityshoes, and neutral cushion shoes—are listed here in Table One). Themost popular shoes are stabilityshoes. Characteristics of the maxi-mum stability/motion control shoeare the largest, densest medial post,straightest last, and maximum

that we see today is towards bare-foot and minimalist running. Inthe category of semi-customizationis the Somnio running shoe. Som-nios were tested at the BoulderCenter of Sports Medicine and con-tain various design componentsthat allow semi-customization inbiomechanical correction. A shoeretailer must be qualified in orderto utilize the technology necessaryto evaluate a runner for Somnios.

Markers are placed upon therunner’s feet, legs, and hips. Therunner utilizes a treadmill, and acomputer evaluates various anglesto determine how much biome-chanical correction this runnerneeds. The technician then utilizesthis information to choose fromthree full-foot varus wedges that areavailable, each with a differentamount of correction built in, threefoot beds each with different archheights, and cushioning inserts atthe first MTPJ and the heel. Somnioattempts to customize shoes basedon the functional needs of the indi-

Athletic Shoes...

Continued on page 114

Figure 4: MBT rocker sole shoe

Unstable ShoesThe unstable shoe category,

made popular by MBT shoes,Reebok, and Skechers, is anothertrend in athleticshoes. This tech-nology was devel-oped based onthe Masai, anAfrican tribe, andhow they walk inthe sand. Theseunstable shoes arealso termed ton-ing shoes. Thetheory behindthem is that theyturn our flat hardartificial surfaceinto a natural un-even ground,similar to walk-ing in sand. Dueto this change in function, these

shoes challengethe core strength-ening muscles tobe more active.This changedmuscle actionthen creates goodposture, and in-creases shock ab-sorption for thejoints, while sig-nificantly reduc-ing musculoskele-tal compression.This technologyappears to be verysimilar to ther o c k e r b o t t omtechnology used

by pedorthists and podiatrists, butthis new technol-ogy is more ag-gressive thanthose previouscorrections were.The lack of mid-and forefoot mo-tion in toningshoes may helppatients withmid-foot andforefoot com-plaints, but onemust be cautiousin placing a pa-tient in such an unstable shoe (Fig-ure 4).

There are even shoes now thatare purported to be more environ-

vidual (Figure 2).Another shoe technology that

has gained popularity is the New-ton shoe. The Newton shoe was de-signed specifically for mid- to fore-foot strikers and actually containswhat are termed actuator lugs,which are raised rubber rectangleslocated in the forefoot of the shoe.At contact, the lugs are pushed intothe mid-sole, where they stretch amembrane. At push-off, the mem-brane rebounds and the actuatorsare pushed from the mid-sole backto the outsole, returning energyinto the forward propulsion (Figure3). Another shoe built along thissimilar philosophy is the Karhu,which encourages minimal heelcontact time and embraces a ful-crum technology to return energyto the runner.

The pose run-ning method de-veloped byNicholas Ro-manov, a RussianPh.D., has beenadvocated by itsproponents to de-crease injuryrates in runners.This is a move-ment methodbased on main-taining a particu-lar strike andbody positionwhere the runnerlands on the ballof the foot, keepsthe foot in an initial position anddoes not push off, but rather pullsthe foot off the ground using thehamstring and allowing gravity tobe the primary force in moving thebody forward. Romanov postulatesthat it is the heel strike, present inmost runners, which is the cause ofmost running injuries, and propos-es his alternative method as a solu-tion to these injuries. The use ofthe Newton and Karhu shoe fitsinto this philosophy. Again, re-search is conflicting in this matter.Multiple studies have shown nometabolic or functional advantagesfor a runner who attempts toswitch foot strike pattern. Gruber,et al. in 2009 in ACSM noted nodifference in oxygen cost.

mentally friendly. Brooks has devel-oped the Mogo mid-sole. Tradition-al mid-soles can last up to 1,000years in landfill. This new material

will change that1,000 years to 20years, thereforemaking it moreenvironmentallyfriendly.

Born to Runby ChristopherMcDougall sug-gests that run-ning long dis-tances barefoot isthe key to happi-ness and longevi-ty. McDougallproposes that theelaborate archi-tecture and cush-ioning of shoes is

a cause of athletic injury. Mc-Dougall bases this conclusion onhis observations of the Tarahu-mara, a tribe noted for their abilityto run extreme distances in diffi-cult environmental conditionswith relatively little injury. Born toRun has created a devoted group ofrunners who have adopted thisbarefoot running trend, either in-corporating it as part of their rou-tine, or moving to training entirelythis way. The book is a vivid tale,but does take dramatic literary li-cense in its interpretation of theevents that are portrayed. It hasbeen, however, a best selling bookand has generated an entire tech-nology behind it.

Keep in mind that once oneplaces any type of material upon

the foot, one isno longer run-ning barefoot.The Nike Free wasone of the firstshoes developedto address theneeds of runnerswho wished torun with minimalsupport and cush-ioning, with justa protective cov-ering for the foot.The Free was de-

veloped with an extremely uniquedesign, incorporating Sipes trans-verse fissures in the sole, which was

Athletic Shoes...

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114 www.podiatrym.comPODIATRY MANAGEMENT • OCTOBER 2010

Research suggests

that cushioning

in running shoes

can cause excessive

subtalar joint

motion.

Figure 5: Nike Free

Patients should

be fit in shoes to

their longest toe,

optimally having a

thumb’s width in

space beyond the end

of the longest toe to

the tip of the shoe.

OCTOBER 2010 • PODIATRY MANAGEMENTwww.podiatrym.com 115

of thoroughly evaluating the pa-tient’s anatomy, function, and in-jury history cannot be overstated.Knowledge and staying abreast ofcurrent shoes and current tech-nologies is essential for the sportsmedicine podiatrist. Even if onedoes not have an extensive sports

medicine prac-tice, one will notbe able to getthrough a day atthe office withoute n c o u n t e r i n gsome or all ofthese shoe issues.

For patientswho wish to in-corporate unsta-ble shoes or bare-foot running intotheir workoutschedule, it is bestto always ap-proach this asone would ap-proach a newtraining activityor training regi-men, with thegradual introduc-

tion of the new entity and constantmonitoring should any problemsarise. This will allow the patient tobest adapt to new techniques andto identify any problems that mayoccur.

The American Academy of Podi-atric Sports Medicine website andrunning shoe page can also helpone in day-to-day practice by pro-viding the most current up-to-dateinformation on shoe technologyand shoe models. Armed with thisknowledge, we are best able to helpour patients make their healthiestchoices. �

BibliographyNigg, BM. “The Role of Impact

Forces and Foot Pronation.” Clin JSports Med (2002): 57-59.

Lafortune, Mario. “The Role of Re-search in the Development of AthleticFootwear.” Journal of Foot and AnkleResearch (2008).

Nigg, B.M., Denoth, J., andNeukomm, P.A. Quantifying the loadon the human body: problems andsome possible solutions. BiomechanicsVII (1981): 88-99.

Nigg, B.M. and Morlock, M. The in-fluence of lateral heel flare of runningshoes on pronation and impact forces.

adapted from tire technology. Thisallows the entire shoe to roll upupon itself, so that there is very lit-tle support that comes from theshoe. The shoe has what Nike termsa better anatomical shape designand is extremelylightweight as themid-sole and theoutsole are thesame material, aphylon rubberblend. In additionto the Free, Nikehas developed theGlide, in which itincorporates 2 de-grees of varus cor-rection in theshoe (Figure 5).

Ecco has alsocome out withthe Biom, whichis more shoe thanthe Nike Free, butstill attempts toadhere to thisbarefoot philoso-phy. The shoemost similar to actually being bare-foot is the Vibram 5 Fingers shoe,basically a rubber protective cover-ing with individual toe structure.This seems similar in many ways toan Aqua shoe in terms of the pro-tectiveness that it provides to thefoot. The more hardcore barefootrunning proponents tend to utilizethis running shoe as it does mostclosely mimic the barefoot condi-tion while providing a protectivecovering for the foot.

SummaryIn summary, advising patients

as to shoe choices is an art. Tech-nology is constantly evolving, con-stantly improving, and constantlychanging. Frequent research de-bates each new technique andtechnology. Running shoe compa-nies are constantly seeking newand better ways to address theneeds of the runner, whether thatbe for greater injury protection,lighter, more comfortable shoes, ornew trends that appear. It is a com-bination of all these approachesand philosophies that can helpguide us as to what is best for ourathletic patients. The importance

Med. Sci. in Sports & Exercise (1987):294-302.

Nigg, B.M., Bahlsen, H.A., Luethi,S.M. and Stokes, S. The influence ofrunning velocity and midsole hardnesson external impact forces in heel-toerunning. J. Biomechanics (1987): 951-959.

Clement D.B., Taunton, J.E., SmartG.W. & McNicol, K.L. A survey of someoveruse running injuries. PhysSportsMedicine (1981) :77-8.

Dressendorfer, et al. “Effect of ShoeCushioning on the Development ofReticulocytosis in Distance Runners.”American Journal of Sports Medicine(1992): 212-16.

Lieberman, et al. “Foot Strike Pat-terns and Collision Forces in HabituallyBarefoot Versus Shod Runners.” Nature(2010): 531-35.

McDougall, Christopher. Born toRun: a Hidden Tribe, Superathletes, andthe Greatest Race the World Has NeverSeen. New York: Alfred A. Knopf, 2009.

Hamill, et al. “Lower Extremity Stiff-ness in Runners with Different FootTypes.” J Biomech. (2000).

Grube, et al. “Metabolic Cost Of Al-tering Foot Strike Patterns In Running.”Medicine & Science in Sports &Medicine 41.5 (2009): 512.

Gruber, et al. “Segment Coordina-tion Response to Alterations in FootStrike Pattern.” American Society ofBiomechanics (2009). Web. 8 May 2010.<http://www.asbweb.org/conferences/2009/pdf/1117.pdf>.

Miller, et al. “Foot-Strike Pattern Se-lection to Minimize Muscle Energy Ex-penditure During Running: A ComputerSimulation Study.” American Society ofBiomechanics (2009). Web. 8 May 2010.< h t t p : / /www . a s bweb . o r g / c on -ferences/2009/pdf/922.pdf.>

Athletic Shoes...

Dr. Langone is agraduate of theNew York Col-lege of PodiatricMedicine. She isa Fellow, Ameri-can College ofFoot and AnkleOrthopedics andMedicine andFellow, Ameri-can Academy of Podiatric SportsMedicine. Dr. Langone is President ofthe AAPSM. She is also Lead Clinical Di-rector in New York State for Fit Feet, apodiatric screening service offered inconnection with the Healthy Athletes®initiative which provides health screen-ings free of charge at Special Olympicscompetitions. Dr. Langone is also amember of the AAPPM. She is in privatepractice in Southampton, NY.

The significance

of shoe construction

is that mid-sole

cushioning stability

devices, the last,

and even the fit

all add up to

determine how

much stability

the shoe provides.