Foot Strike and Injury Rates in Endurance Runners

New research recently (Jan 2012) released by Dr. Daniel Lieberman and his team at Harvard University, evaluates the injury statuses of a mixed sex collegiate cross country running squad of 52 athletes, looking back across a season. Researchers classified each runner in terms of foot strike type: “Rearfoot (Heel) Striker” or “Forefoot Striker“, and evaluated the injuries reported in the two groups. Of the 52 strong group, 69% were Heel Strikers and 31% Forefoot Strikers.

It turns out that 74% of the total group suffered significant running injury during the season – which follows figures suggested by injury surveillance studies in endurance running.

The interesting part… the Rearfoot (Heel) Strike group suffered approximately double the rate of repetitive stress related running injuries, in comparison to the Forefoot Strikers.

Foot Strike and Injury Rates in Endurance Runners: a Retrospective Study

Purpose: This retrospective study tests if runners who habitually forefoot strike have different rates of injury than runners who habitually rearfoot strike.

Methods: We measured the strike characteristics of middle and long distance runners from a collegiate cross country team and quantified their history of injury, including the incidence and rate of specific injuries, the severity of each injury, and the rate of mild, moderate and severe injuries per mile run.

Results:Of the 52 runners studied, 36 (69%) primarily used a rearfoot strike and 16 (31%) primarily used a forefoot strike. Approximately 74% of runners experienced a moderate or severe injury each year, but those who habitually rearfoot strike had approximately twice the rate of repetitive stress injuries than individuals who habitually forefoot strike. Traumatic injury rates were not significantly different between the two groups. A generalized linear model showed that strike type, sex, race distance, and average miles per week each correlate significantly (p<0.01) with repetitive injury rates.

Conclusions: Competitive cross country runners on a college team incur high injury rates, but runners who habitually rearfoot strike have significantly higher rates of repetitive stress injury than those who mostly forefoot strike. This study does not test the causal bases for this general difference. One hypothesis, which requires further research, is that the absence of a marked impact peak in the ground reaction force during a forefoot strike compared to a rearfoot strike may contribute to lower rates of injuries in habitual forefoot strikers.

© 2012 The American College of Sports Medicine

Here’s My Coaching Perspective:

I’m not pro or anti forefoot striking or heel striking as a blanket positioning statement as a coach. The subject isn’t that simple when you’re dealing with individual athletes and their idiosyncrasies, individual strengths and weaknesses.

FYI: I’m a forefoot/midfoot runner myself and can 100% testify to the benefits – as one of those for whom it is appropriate for as a style…

I agree that habitual forefoot strikers tend to get injured less, and it probably is linked with the absence of a marked impact peak in the ground reaction force during a forefoot strike compared to a rearfoot strike. BUT what’s so often not written about is how the impact peak cited in the conclusion section above can also be greatly reduced by staying as a heel striker and simply landing the heel strike closer to under the center of mass… without having to make such a wholesale change as moving onto the forefoot – which can lead to injuries in it self.

If I’m working with an athlete who is strong enough to maintain a forefoot position, had an appropriate injury history, and was training for a suitable distance – I’d definitely encourage them to adopt a forefoot position. However, if I did this with every athlete I work with, there’d be some very broken runners leaving my care!

Then there’s the importance of the goal distance. Research by Pete Larson (@RunBlogger), published in 2011 entitled “Foot strike patterns of recreational and sub-elite runners in a long-distance road race” shows that a significant proportion of those who start long distance (marathon) running events as forefoot runners in the first 10km, often end up as heel strikers by the end of the race.

I’d be interested to see if anybody continues the injury surveillance and biomechanical research to subcategorise heel strikers. The categories could be:

• Those who heel strike AND over-stride with a low cadence
• Those who heel strike and maintain a contact closer to under their center of mass through keeping a relatively high cadence.  Therefore still experiencing less impact without going the whole way to a forefoot strike.

All food for thought… 

 

8 Comments

• 
  Brian Martin January 12, 2012 at 8:58 pm

  G’day James, You’re spot on with this analysis. Being a heel-striker is not necessarily such a bad thing. There are plenty of heel-strikers out there who can A. run very fast and B. do it without being injured. As you’ve suggested the Lieberman studies are useful but not the complete picture as they don’t look from the hips down. If this was measured we could better classify the heel-strikers by how well they activate their buttocks and hamstrings.

  As an aside there are a number of forefoot strikers I have seen while coaching that do not activate their hamstrings and glutes quickly enough and therefore over-stride. Getting on your forefoot in this case isn’t all it’s cracked up to be and could possibly carry more risk of injury. Regards Brian

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• 
  Suzanne Atkinson January 22, 2012 at 9:44 pm

  James, I agree with your assessments about being able to lower impact force of heel-strikers by changing stride, but not landing (fore/mid/heel). ALthough I’ll just point out that this was a retro-spective study without surveilance. The runners were not followed, simply evaluated and classified. Further research would then be based on these findings, or other hypothesis for prospective analysis. Some blinding by sports physicians and therapists would add to the value of future studies as well.

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• 
  Leon Boone April 4, 2012 at 3:08 pm

  This article bring up some good points. I agree that the impact force is caused by over extending your legs not necessarily by landing on your heel. I think this is where cadence can come into play as well. If you keep a high cadence then you are more likely to not over extend your legs out in front of you.

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• 
  Athena T.Visel July 18, 2012 at 1:48 pm

  Great article! I like how you acknowledge not all athletes are the same, and there is no “one-mechanics-fits-all”. Proper research is a very difficult thing to accomplish, so it’s always good to know it’s taken with a grain of salt, so to speak.

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• Foot Strike and Injury Rates in Endurance Athletes | EightLane November 12, 2012 at 5:42 pm

  [...] Full Article HERE [...]

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• 
  janedoemuc November 18, 2012 at 2:59 pm

  Quote: “The interesting part… the Rearfoot (Heel) Strike group suffered approximately double the number of repetitive stress related running injuries, in comparison to the Forefoot Strikers.”
  End quote.

  Frankly I am a bit surprised of that statement, because that is not very interesting and not very surprising as the rearfoot strikers of the example above provide with 59% almost the double number (in percentage) of the forefoot strikers (31%). I wonder what kind of “strikers” the remaining 10% were? (59 + 31 = 90, not 100) Or do I get my math wrong?

  And there are still more rearfoot strikers out there than forefoot strikers. So more injuries in rearfoot strikers than in forefoot strikers come as no surprise to me…independently from research. Just applied common sense. Cheers. janedoemuc

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  • 
    James Dunne November 18, 2012 at 3:20 pm

    Janedoemuc,

    Thanks for taking the time to leave a comment. Especially as it pointed out a couple of typos!

    I’ve just checked the original research again. You’re right, it is 69% not 59%.

    Also in terms of the injuries reported. I’ve should have said “rate of repetitive stress related running injuries” rather than “number of repetitive stress related running injuries”. Makes far more sense now I hope!

    That said, the sample size of this study is too small to read anything into the findings.

    The whole aim of this blog post is to share my thoughts on the coaching relevance and application of such research – as per the discussion points added after the abstract.

    Reply
• Draft – How To Run Injury Free and How To Stretch Your Calves | TheTriTouch November 23, 2012 at 5:45 pm

  [...] While recent research by Prof. Daniel Lieberman et al (2012), strengthens the argument that habitual forefoot and midfoot runners suffer fewer injuries and enjoy increased running efficiency, the findings need to be applied with caution. Read the following review of the new research to get my coaching perspective… [...]

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