Sports Medicine Research: In the Lab & In the Field: Pronated and Neutral Wins the Race…or at Least Keeps the Runners in it (Sports Med Res)


Wednesday, July 17, 2013

Pronated and Neutral Wins the Race…or at Least Keeps the Runners in it

Foot pronation is not associated with increased injury risk in novice runners wearing a neutral shoe: a 1-year prospective cohort study.

Neilsen RO, Buist I, Parner ET, Nohr EA, Sorensen H, Lind M, and Rasmussen S. Br J Sports Med. 2013; [Epub Ahead of print].

Take Home Message: Novice runners with pronated feet may sustain fewer injuries than neutral feet, when they wear neutral running shoes.

Among runners foot pronation is believed to be a strong predictor for athletic injury. While certain athletic shoes are commonly prescribed for individuals with pronated and supinated feet, there has been conflicting evidence to support this. Therefore, Neilsen and colleagues completed a prospective cohort study “to investigate if running distance to first running-related injury varies between foot postures in novice runners wearing neutral shoes." Investigators recruited participants through posters and mailings distributed to local companies to target participants interested in taking up running. Potential participants completed an online questionnaire to screen gender, age, running experience, health, previous running-related injuries, and previous injuries not related to running.  Participants were included if they were (a) healthy, (b) between 18-65 years of age, (c) had no injury of the lower extremity for at least 3 months prior to the start of the study, (d) able to access the internet, and (e) not running on a regular basis. Participants were excluded if they (a) participated in another sport for more than 4 hours per week, (b) used insoles during training, (c) were pregnant, (d) reported a history of strokes, heart disease or chest pain during training, or (e) were unwilling to participate in the study. Investigators classified 1,854 feet from 927 participants into 1 of 5 foot posture groups based on the Foot Posture Index (FPI): highly supinated (53 feet), supinated (369 feet), neutral (1292 feet), pronated (122 feet), or highly pronated (18 feet). Investigators issued neutral running shoes and a GPS watch to the participants and instructed participants to upload data from every training session, via the GPS watch, to an online personal training diary. If an injury occurred, participants contacted the research team and they scheduled an appointment for a clinical examination. The investigators classified injuries as either “running-related” or “other”.  At a 1-year follow-up, the rate of first-time injury was 17.4% for neutral feet, 17.9% for supinated feet, 24.5% for highly supinated feet, 13.1% for pronated feet, and 33.3% for highly pronated feet. Overall, the investigators found no differences among highly supinated, supinated, pronated, and highly pronated feet when comparing to neutral feet with regards to injury rates at different running distances – 0 to 500 km. Conversely, pronated feet were less likely to sustain injury per 1000 km of running than neutral feet.

Overall, the investigators found that a person with a pronated foot, in a neutral shoe, was less likely to incur an injury compared to neutral feet in the same shoe. Unfortunately, this was not the case for other foot types (supinated or highly pronated); however, this study provides clinicians with some good information. During evaluation, when clinicians observe foot type, they should also evaluate the athlete's shoe type and condition to better advise the patient with regards to proper foot wear. Since the current study only used neutral shoes it is difficult to only recommend neutral shoes to patients as future research may find another shoe type more beneficial. Secondly, the data in the current study leaves to door open for other foot types to be paired with an equally effective type of shoe. This is where future research can greatly impact injury prevention. Currently, only part of the puzzle is complete. More research should look to focus on different levels of running experience and other shoes types. Conceivably, one can see a gold standard of shoe type that is recommended based on the athlete's foot type and level of running experience.  

Questions for Discussion: Do you currently screen athletes for foot type prior to activity or as part of your preparticipation physical exam? If not, would you consider doing this now that you have seen that this could impact the number of running injuries?

Written by: Kyle Harris
Reviewed by: Jeffrey Driban

Related Posts:

Nielsen RO, Buist I, Parner ET, Nohr EA, Sørensen H, Lind M, & Rasmussen S (2013). Foot pronation is not associated with increased injury risk in novice runners wearing a neutral shoe: a 1-year prospective cohort study. British Journal of Sports Medicine PMID: 23766439


Peter Bird said...

They screwed up. They used the wrong cut off for the Foot Posture Index. Almost all in the "neutral group" were pronated. Anyone familiar with the Foot Posture Index will tell you that.

Jeffrey Driban said...

For those that are interested:
The authors defined neutral as a score of 1-7 (under 60 years of age) and 1-8 (over 60 years of age). Traditionally, 0-5 is neutral. The cutpoints used by the authors were based on

Since neutral was more grossly defined than typical and pronated more narrowly defined this could have decreased the chances of finding differences between neutral and pronated feet. Instead, the authors found that over a long distance the pronated feet (or if you would feet with "definitely pronated feet scores)" had less injuries. It would have been beneficial if they had analyzed the FPI as a continuous variable so that we could determine what FPI score best separated those with or without risk of injury.

Jeffrey Driban said...

It would be interesting to know if the authors plan to follow-up this study with a randomized clinical trial to really help figure out if the neutral shoes reduce the risk of injury among people with pronated feet.

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