Did the new shoes cause my heel pain?


Yesterday I was asked a question about changing shoes and heel / arch pain. By the time I’d answered it, I realized I’d written the majority of a blog. So here goes…..

Details sent to me:

Female early 30s returns to running regularly after a long period of without training. Purchases the Hoka One One Challenger shoe (shown in image). The patient gradually increased training mileage to + 6 miles and was incorporating flexibility and some strength training into her regime over a period of 4 months. One week after transitioning back into a lighter Nike Shoe also pictured and is experiencing pain on the left medial arch (waiting on athletic trainer assessment later today but possibly plantar fasciitis as pain spreads further under arch).

UPDATED DIAGNOSIS: VERY tight Flexor Hallicis Brevis and Flexor Digitorum Brevis (small foot muscles), with a little “knot” in there too, worked out manually by the AT and also did some ultrasound. Will rest for a day or two and then try it out again.

Is it feasible that the foot muscules may have de-trained in the highly cushioned shoe, leading to this flaring up once a shoe with lower arch support and overall cushioning is worn?

My Response:

Returning to training after a period of time off does risk a gradual accumulation of overload associated with overuse injury. That said it seems you have managed this carefully over a period of 4 months so this is not screaming at me (Tip: keep a simple excel file of weekly mileage / minutes, I find it stops you making any sudden jumps when you have a record of what has gone before). Generally speaking, the body is designed to adapt to stress caused by exercise and yours seems to have done so gradually overtime in shoe type A. Switching to shoe type B does however does constitute a sudden change in load. Although there is no increase in total running – for the previously underused parts of the body /foot (when using shoe type A) changing to shoe type B is like a sudden increase in mileage. This is lightly where the issue has arisen from. My personal view is that you could have got the same outcome changing from many different types of shoes to another (I think these changes are about change in overload to the affected tissue not a mm + or – arch/heel/toe etc.). Something that shoe type A and shoe type B (which I don’t regard as minimalist although more so than shoe type A) have in common is that they both reduce proprioceptive (sensation or feeling) input to the foot. When you can’t feel what is happening underfoot you tend to be more careless in the way you plod (or slap) along. To see what I mean take off your shoes on a stretch of tarmac or concrete along a footpath or cul de sac (free from glass, debris etc.) and walk a little, see how much more care you take. Females with a history of plantar fasciitis have higher loading rates (tendency to ‘slap’ along) than those without. I suggest the absence of the need to protect your foot in either shoe will lead to an increase in loading to the foot in this case the plantar fascia or the smaller flexor tendons (muscles under foot). It may be that the extremely cushioned shoe A (which remember you progressed very slowly in from the start) could somehow compensate for this loading to a greater extent than the less cushioned shoe type B. As pointed out to me by my colleague Dr. Sarah Clarke from Northern Michigan University, it may be that there was increased demand on these small foot muscles when using shoe type A (and potentially I think less work being done by the bigger and stronger calf muscles) and when a lighter shoe with less arch support was used subsequently, these small overworked muscles couldn’t cope with the strain.

We have recently published a case report using barefoot running on a soft grass surface as a method to reduce pain and restore function in a female runner with plantar fasciitis (MRI diagnosis). However, adaptation to barefoot/minimalist running would take the same care (in fact more so) in build up as you used in shoe type A as this would be a very acute change in load. This should be experimented with in small amounts(<15 minutes in the beginning), with caution and on the appropriate surface. A soft grass surface will be most useful as it will deform under foot but also these surfaces tend to have higher variability to spread the load (just look at a mucky field compared to a smooth slab of concrete and think about which surface will be more repetitive). I think the integration of some of this type of running is key if you want your muscles (particularly the calf muscles) to help control the foot rather than allowing the foot and its smaller muscle to be subject to excessive loading. Philosophically if I was to go against my own bias I am wondering is the solution particularly for those without a preference for barefoot training – not just to wear shoes but to wear super cushioned shoes as is the case in shoe type A. Could gradual progression in these shoes provide a viable and more socially acceptable alternative? Perhaps but certainly when it gets to the performance end of the scale, the increases in oxygen consumption required to use such shoes may make them unsuitable for those who have time as a goal. They could train heavy and race light but does that also increase injury risk? Personally, I think the sensory input is key – but like every new training stimulus it must be done slowly. As I started with – key here is to try to avoid sudden changes in load whatever you are or are not wearing.

In case anyone is wondering what shoes I wear running, they are pictured below. Why these ones? They were the lightest and cheapest in the store (beware: I have built up to running in light shoes gradually over time).