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Solid Footing

Gait analysis can help therapists recommend proper shoe fit for injured athletes
By Bruce R. Wilk, PT, OCS, and Anthony R. DiMercurio

 

Following a running-related injury (RRI), patients often seek guidance on proper shoe selection. It is vital for sports rehabilitation clinicians to be able to identify and evaluate patient need, offer recommendations, and isolate defective or worn out shoes.

A safe and proper return to participation begins with an appropriate pair of running shoes and a sound training program. Choosing a shoe free from defects and based on individual gait analysis has afforded injured patients a faster return to safe running.1

Gait Analysis in Shoe Selection

Archive ImageWhen purchasing the ideal running shoe, patients should begin by consulting with a specialty running shoe store. Most specialty running shoe stores routinely use video gait analysis on a treadmill, to provide baseline information about an individual's specific needs before recommending any running shoes. Video gait analysis is an effective way to observe and analyze individual biomechanics, as an evaluation of full gait is required to adequately analyze the patient's foot and gait pattern.2

Minimalist shoes and racing flats should be used for the initial video gait analysis so the shoe doesn't affect gait mechanics, such as pronation.2,3 It is not safe for patients to run barefoot on a treadmill; thus, barefoot running should never be used for any video gait analysis. Before taking the patient on the treadmill, make sure all metatarsals of the foot are sitting evenly on the shoe platform, taking notice of the width of foot. Any portion of the foot sagging over the edges is a signal of an improper fit and can lead to an inaccurate analysis, as well as discomfort.

 

Elite high school and collegiate athletes travel to Philadelphia every April for the Penn Relays, the oldest and largest track and field competition in the United States. With technological advances such as video gait analysis, sports rehab clinicians are better equipped to make training and equipment decisions to keep these high-level athletes healthy and injury free.

During video gait analysis, look for non-neutral gait patterns, and listen to the sound of the foot strike. Once videotaped, analyze the gait pattern in both slow motion and at full speed to precisely evaluate any signs of overpronation or supination. Evidence of overpronation or supination, proven by video gait analysis, can help the patient select a shoe that works for their gait pattern. With a significant amount of overpronation, the patient will benefit from a more stable, supportive shoe, classified in the stability category. Limiting the amount of movement in the rearfoot allows the patient to have maximum support upon foot strike.

A study presenting rearfoot motion with neutral shoes versus stability/motion control shoes proved that a runner in a neutral shoe had a 6.5-degree movement while the stability/motion control was significantly less.4 These shoes come equipped with medial posting and firmer materials built into the shoe to help prevent the overpronation during foot strikes. A patient who supinates will benefit from a less-stable, more cushioned shoe, providing more impact-resistant materials such as gel and air.

The salesperson at a specialty running shoe store should know how to properly analyze gait and must also be knowledgeable about a variety of different shoes in a variety of brands. The salesperson should attempt to fit as many shoes as possible, keeping within the category recommended for the patient. Once a few shoes have been narrowed down, the patient should try on the different shoes and focus on the comfort and fit of the shoe.

Specifically, the fitter should observe how the shoe moves when striking the ground, how the rubber compresses on the foot, and the patient's overall subjective comfort level. With the new shoe, have the patient run on the treadmill, and analyze gait mechanics during initial contact, midstance and push-off.

Check whether the shoe is digging or rubbing on any portion of the foot. A patient running with too much support will present a clucking sound upon foot strike, whereas a patient running with too little support will present a slapping sound upon foot strike. Most importantly, ask the patient if the shoe feels like it's a part of the foot. A well-fit shoe will feel like a continuation of the foot.

Runners, historically, have used more supportive shoes early in training and progressed to lighter weight and less platform later in training. This traditional concept of running may work for seasoned athletes, but for injury management, always go with more shoe, as more support is necessary for safe, initial return to participation.

Upon return to participation, the patient's feet are reintroduced to body weight load. Sudden body load increase can stress healing muscles and bones. Load stress brought on by overpronation is increased up to 200 percent; thus, the control of initial pronation (support shoes) is much more important in running shoe design than cushioned shock absorption.5 Therefore, if a patient is nursing an injury, more load support will likely increase safe injury management.

Detecting Defective Running Shoes

Avoiding defective running shoes is critical to preventing further injury. An athletic shoe should be constructed so that its upper, midsole and outer sole is firmly attached. Inflexible shoes can cause calf muscles to overwork and can contribute to the development of specific injuries.6

Before recommending a shoe, check its construction. The shoe should continuously be glued together correctly at all locations. The upper (mesh portion) should be glued straight into the sole. The sole of the shoe should be level to the surface it is resting on.7 Check for asymmetry from side to side on each shoe. If the shoe can be rocked, then it may not adequately support the foot from rolling excessively when worn.

When using a shoe with air pockets or gel pockets, check to see whether those materials are still inflated. Sometimes, the support technologies within the shoe tend to deflate, thus leaving the shoe purposeless. A shoe should have flexibility, with the flex occurring specifically at the metatarsal heads, the widest portion of the shoe (toe box).8

Furthermore, when choosing a running specialty store, be sure that the shoe selection is always current. An older model shoe that's been discounted may not be the best choice because some materials within the shoe, such as gels and rubbers, do have a limited shelf life.

A safe return to running activities should initially begin with some fitness walking with full heel-to-toe motion, and progress to gliding, which is flat-foot initial contact for long, slow distance. The shoe should allow an individual to move through a full gait heel-to-toe motion. A forefoot gait pattern is practiced and refined later with accelerations during training and plyometric exercises.

Physical therapists, athletic trainers and associated rehab personnel should consider the kind of injury, extent of the injury, and training level of each individual before recommending a return to a training program. Refining performance should focus on biomechanical energy efficiency.

This applies to a precisely fitted shoe. Foot strike energy should be returned at the right location at the right time and a reduction of energy is more important than return of energy.9

Reducing the amount of energy upon foot strike for a patient returning to participation thus allows the patient to safely return to activity progressively through the correct fitness regime.

Presenting ample knowledge on shoe recommendations can greatly improve the outcomes of injury management regimes. Provided with accurate information, a patient suffering from a RRI can safely and successfully return to running.

References

1. Gabor, J. (2006). Computational intelligence for movement sciences: Neural networks and other emerging techniques. Ed. Rezaul Begg. Hershey, PA: Idea Group Publishing.

2. Whittle, M. (2002). Gait analysis: An introduction. Third edition.

3. Wilk, B. (2007). The Nike Free as a useful tool for video gait analysis. http://www.thefreelibrary.com/The+Nike+Free+as+a+useful+tool+for+video-gait+analysis-a0171020562

4. Cheung, T., Roy, H., Ng, Y., et al. (2006). Efficacy of motion control shoes for reducing excessive rearfoot motion in fatigued runners.

5. Murphy, V. (2004). The efficacy of subplantar cushioning in modulating ground reaction force and total impulse in normal walking gait. http://www.medicalengineer.co.uk/pages/rehabilitation-engineering/gait-analysis.html

6. Denoth, J., & Stacoff, A. (1988). Running injuries and running shoe construction: Demonstration of possible correlations. http://www.ncbi.nlm.nih.gov/pubmed/3242154.

7. Wilk, B. (2000). Defective running shoes as a contributing factor in plantar fasciitis in a triathlete. http://www.ncbi.nlm.nih.gov/pubmed/10705593.

8. Pribut, S. (2009). Selecting and fitting a running shoe. http://drpribut.com/sports/spshoe_fit.html

9. Segesser, B., & Nigg, B. (1993). Orthopedic and biomechanical concepts of sports shoe construction. http://www.ncbi.nlm.nih.gov/pubmed/7908458.

Bruce R. Wilk is director of Orthopedic Rehabilitation Specialists, Miami, FL, president of The Runner's High, and head coach of the Miami Runners Club. Anthony R. Di Mercurio is studying his physical therapy prerequisites and is a sales associate at The Runner's High



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