Benefits of Barefoot Running for Injury Prevention w/ Dr. Peter Francis
Written by Christopher Ioannou, featuring Dr. Peter Francis
Reading Time: 16 minutes
Table of contents
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The video version of this podcast:
This blog post is a summarized version of a 60-minute interview (linked above) with Dr. Peter Francis on the benefits of barefoot running for injury prevention, the top 7 things everyone should include in their running programs and much more.
Dr. Francis is a sports and exercise scientist from Ireland who specializes in research on sports rehabilitation and human gait biomechanics. He has also taken a keen interest in the topic of barefoot running, and how the physical activities of human beings have changed since the times of the hunter gatherers.
Dr. Francis’s interest in these topics grew out of his own personal experience of plantar fasciitis, a common injury among today’s runners. After developing the condition himself and trying all kinds of failed treatments, one of his friends suggested running barefoot on grass. Dr. Francis took his friend’s advice and was able to totally eliminate his plantar fasciitis in just a short time running barefoot.
This experience sparked off his interest in researching the mechanics of barefoot running and how it could help others claim back their ability to run injury free.
Learn More About Dr. Peter Francis and His Research
The Exercising Health team and I thank Dr. Francis for taking the time to be interviewed by us and for sharing his knowledge with all our viewers.
We highly recommend reading his blog and following him on twitter and instagram. You can also find all his published academic work here.
Prevalence of Running Injuries
In a 2018 study on lower limb running injuries, Dr. Francis stated: “Running is associated with a higher risk of overuse injuries than other forms of aerobic exercise such as swimming and cycling.” So, we asked him why it was that running—a primal movement that, as children, we perform without instruction—results in more injuries than swimming and cycling, which had to be taught.
He replied that the main reason was that there was more of a muscular-skeletal demand on the body when running due to the deceleration forces acting on the body through gravity. By contrast, there was far less impact in swimming and cycling.
However, he said that the reason for which injury rates were so high among runners, despite it being a primal human movement pattern, was because nowadays humans have become sedentary and are not as conditioned to running as they were in the past.
Furthermore, running surfaces and footwear had changed significantly in recent years, and our bodies had not been able to adapt to this rate of change.
The Benefits of Barefoot Shoes Over Regular Running Shoes
In a literature review Dr. Francis published in 2020, in which he compared hunter gatherers to the modern runner, he described the incompatibility of modern shoe designs with our natural foot function as “a mismatch between evolutionary biology and cultural evolution.” We asked him to elaborate on this issue.
Dr. Francis explained that the action of modern day running, as a sport, had extremely low movement variability. The pace, surface of the ground and the interior of running shoes were all uniform and, therefore, did not introduce much variation into each step. By contrast, our hunter gatherer ancestors, who varied their pace depending on their circumstances, ran on rough and undulating terrain and did so barefoot or in thin sandals, all of which allowed the body and feet to experience much variation in their loading patterns on each step.
Now, when the tissues of the lower limbs are loaded in the exact same way, without much variation, it will eventually lead to overuse injuries, which is what we are seeing nowadays.
Barefoot shoes can help in this regard by reducing one of these constants. While a regular thick-soled running shoe dampens the foot’s sense of even slight imperfections in the running surface, barefoot shoes enable the feet to feel, and to slightly adjust their position in response to every sensation. Even stepping on road reflectors on a zebra crossing with barefoot shoes would introduce a slight bit of variation that would be lost with regular footwear.
The Reason for The Low Rates of Injury Among Elite Runners
Despite the availability of sufficient evidence to show the injury prevention and performance benefits of the barefoot style gait, elite runners such as Eliad Kipchoge continue to break world records and remain injury free despite wearing maximalist running shoes. So, we asked Dr. Francis why we saw this contradiction in the world of running.
Dr. Francis responded by first pointing out that we could not compare the general population to the world elite, because these high-level athletes were genetic anomalies who had “special” innate characteristics that were not seen in the average sample group.
He observed, as an example, that the East Africans seemed to dominate distance running. The lifestyle of this demographic differed a lot to the rest of the world. Moreover, factors such as poverty and the desire to escape that life through running engendered a strong mental drive in these runners.
However, more practically, we know that East Africans grow up barefoot, to a large extent, and would certainly grow up being a lot more active, out of necessity, than people growing up in more developed regions of the world. Therefore, when children grow up in this way, they adapt by developing all the bodily structures required to handle such a lifestyle.
As Dr. Francis eloquently stated in this interview, “By the time they are adults, you could probably put a pair of wellington boots on them and they’ll still remain in pretty good shape.”
The Importance of Runners Growing Up Barefoot
Continuing with this train of thought, I asked Dr. Francis how important he felt it was to grow up barefoot, and thereby develop strong feet and favorable movement patterns at an early age, both from an injury prevention perspective and for performance.
He responded that he felt the importance was huge, but there was not sufficient longitudinal data available yet to prove the significance. However, he mentioned that he and his colleagues would be focusing on this research in the future.
He went on to explain, however, that, just like adult bone mineral density, which was heavily impacted by our lifestyle in our childhood and teenage years, other musculoskeletal characteristics would also be impacted by the way we were brought up.
Dr. Francis’s words reminded me of a study published in 1995, in The Journal of Bone and Joint Surgery, in which it was found that children below the age of six who spent eight or more hours per day in shoes had a significantly higher prevalence of flat feet later in life than those who were shod for fewer hours at a young age.
The Prevalence of Flat Feet
I then went on to share the results of a recent poll we conducted on our Instagram page, in which we posed the question, “Do you have flat feet?” Of the nearly 1,000 respondents, 52% answered “yes”.
I asked Dr. Francis why he thought so many people had identified themselves as having flat feet.
He responded by saying that he doubted that this many people had the flat foot deformity that is known as “ rigid flat foot.” What was probably present here was fallen arches, commonly referred to as “acquired flat foot.”
While the former case is an actual flat foot deformity that one is born with, the latter is a condition one develops over time due to intrinsic foot muscle weakness.
Interestingly, Dr. Francis mentioned that paleoanthropologist Daniel E. Lieberman had demonstrated that there were almost no signs of flat feet in the archeological records. This suggested that having flat feet was a modern-day issue caused by lifestyle factors.
The Importance of A Proper Barefoot Transition Period
Despite barefoot shoes being a solution to unfavorable movement patterns and unnatural foot structures, rushing the transition from maximal to minimal shoes can actually exacerbate any issues one has. This is often the argument against barefoot style movement and barefoot shoes.
So I asked Dr. Francis what his thoughts were on taking the necessary time to transition properly to barefoot-style movement.
He responded that there were many methods one could use to successfully adapt to barefoot style movement, but the key point was that one had to take the necessary time to adjust.
Dr. Francis said he had found, in his personal experience and in experiments, that barefoot running on various surfaces such grass were a big help during this transition.
He also recommended that people self-select their running speeds during this process and that they keep the dose to 10–15 minutes at first.
The Importance of Proper Barefoot Running Technique
I asked Dr. Francis what his thoughts were on teaching the correct running technique to those who were running with or without shoes.
He replied that it was important, but the beauty of barefoot running was that the body naturally made all these changes automatically. In other words, once the sensory information was there, through being able to now feel the environment, the body naturally adapted its technique accordingly.
For example, while it was comfortable to heel strike in regular shoes, it became painful to do so in barefoot shoes, so one naturally shifted one’s foot-striking pattern to the forefoot, where this pain could not be felt.
These words brought to mind a published case study conducted by Dr. Francis in which a woman with plantar fasciitis was able to totally eradicate her injury by just running barefoot.
This being said, he did mention that not all people adapted so easily to barefoot style gait patterns. Such people would need to be coached accordingly, and might need to have a different intervention.
Learn more about barefoot running technique in our blog post: BAREFOOT RUNNING TECHNIQUE SIMPLIFIED | WHY IT IS SO EFFICIENT
Self-Experimentation Is the Key to Success in Sport
Dr. Francis explained that not everything in the world of sport science was black or white. Much was learned intuitively, and through trial and error.
Ironically, some of his best academic work has stemmed from something he observed or experienced, which sparked off an idea that he ran with—similarly to how Newton discovered the law of universal gravitation by observing an apple falling from a tree.
One particular experiment, which Dr. Francis calls his best work, derived from looking out of a window and observing school children running barefoot on a hard track. He went on to publish the resultant study, which can be found here.
It is therefore, important to remain open-minded and inquisitive, and to not “over intellectualize science to the point where we are dying in boxes,” as he put it.
The Link Between the Glutes and Feet in Running
Shifting back to the topic of functional anatomy, I asked Dr. Francis if he was familiar with the theories and work done on the connection between the feet and glutes, and whether he felt it was worthwhile to try to develop proper glute activity by focusing on the function of the feet.
Dr. Francis started off by saying that it was important to use these connections to ask more questions, but that we should keep our answers “wide,” because there were usually many factors involved in how something worked.
That being said, Dr. Francis did acknowledge the connection between the feet and the glutes, because the whole body was one unit.
He explained that he had found that once one got more sensory input through the feet, the lower limb biomechanics, from the ankle to the hip, changed. This affected how the glutes behaved in the system. Therefore, he emphasised trying to start thinking in terms of whole body systems, rather than trying to isolate one or two segments of the body.
The Cause of Knee Injuries From Running
Moving on to the topic of knee injuries. Dr. Francis co-authored a study in which knee injuries were found to be the most common among runners, regardless of gender. I asked him to elaborate on these findings and explain why the knees seemed to bear the brunt of running.
Dr. Francis started off by mentioning that the basics, such as proper running mechanics and our level of conditioning, were two important factors to consider.
He said that the knee was an interesting one, because when one lost the ability to land on the limb effectively, whether after a jump in field sports or in running, the knee became compromised and the possibility of issues developing in this area of the body started to arise.
The Link Between the Glutes and Knees in Running
He explained that the hips and glute muscles were the major players in preventing poor knee mechanics during landing and lower limb force production, because they controlled the movement of the femur. Unfortunately, due to all the sitting humans did these days, it caused weakness and dysfunction in this posterior chain.
What ended up happening, as a result, was that the anterior structures such as the quadriceps started to become more active in trying to stabilize the knee. Then the balance between the posterior and anterior chain was lost.
However, he said that one must be careful not to then make the assumption that the quads are less important than the glutes. The truth is that the quads and glutes work synergistically with one another.
So, the emphasis should be on trying to restore balance and coordination between these two structures, so that they can work together in harmony instead of trying to dominate one another.
This balance can be achieved by working on the correct movement strategies, because when the joints are put into the correct positions, the groups of muscles have no choice but to work together correctly.
The Link Between the Knees and Feet in Running
I then asked about the link between the knees and the downstream joints, that is, the ankles and feet.
Since the knees are situated between the hips and feet, the downstream joints should affect the knees as much as the upstream joints. I asked him if he thought that the high level of knee injuries was then due to the compounding effect of having structures on both sides of the knee affecting it.
Dr. Francis agreed that the knee could certainly be affected by both the upstream hip and the downstream ankle and foot.
This goes back to the original conversation about the hunter gatherers. Their lifestyles are conducive to building strong and springy Achilles tendons, robust foot arches, powerful glutes, functioning quads and all the other necessary components of a proficient mover.
So, it is difficult to always know if the problem is derived from the downstream or upstream joints. Dr. Francis said that his feeling was often that it was both, because, once again, the body was a unified system.
Knowing When to Change One’s Running Technique or Training Program
Dr. Francis said we should not be too hasty to make severe changes to the way our athletes move and train, even if we feel that some improvements can be made. In other words, if it’s not broken, don’t fix it.
I then asked him if it made sense to wait for an athlete to experience a trauma such as an injury before intervening. Isn’t this too late? Furthermore, are we not also chasing performance, which requires us to critically analyze things and seek out what we think can be improved upon?
Dr. Francis responded by saying that we should do the following when working with an athlete:
Firstly, we need to weigh up the cost vs. the benefit of telling the athlete to make a specific change to their technique or program. This is because everything has a negative consequence. Therefore, we must be extremely confident that if we disrupt the rhythm of the athlete by making changes to their program, that the potential upside will compensate for the disruption.
Secondly, one should make very small changes at a time, to prevent overwhelming an athlete with too many new things at once.
How to Improve Athletic Performance and Reduce Injury Risk in Runners
To finish off this interview, I asked Dr. Francis what general advice he would give to all runners involved in improving their athletic performance and trying to avoid injury. While this was a tough question to answer, due to the specific needs and circumstances of each individual, he did provide the following advice:
One needs to first accept where they are in their fitness journey and then come up with a list of things that need to be done for progress to be made. One also needs to realize that this process requires a lot of patience. Dr. Francis related this to the 10 years it took him to overcome his running injuries.
However, one should not focus on such a long period of time at once. Instead, start with an eight-week block of training and, once that block is completed, start a new eight-week running program and so on. Dr. Francis has written loads about this topic on his blog. You will find it under the “running from injury” tab.
The 7 Things to Include in Your Running Program
Furthermore, he shared seven points that need to be considered when developing a running program:
Design a variable program in which no two days are the same.
Think about the amount of running you can do comfortably.
Try to complete a plan of 8–10 weeks.
Keep a spreadsheet of your training on which it is easy to see what you have been doing.
Engage in some form of strength and conditioning.
Incorporate 10–15 minutes of easy barefoot running on grass at least a couple of times a week.
At least once a week, run as fast as you can, preferably up a hill.
Dr. Francis finished off by saying that one should develop the right headspace regarding running. In other words, running should not be rushed or done with anxiety. Instead, it must be prioritized as an important part of one’s weekly schedule.
Why We Should All Be Running Uphill
Out of all the items on the list given by Dr. Francis, I was curious as to why he specifically advised one to run up hills as fast as possible, so I asked him why he included this recommendation in his program.
He replied that, from a biomechanical perspective, running uphill is unique because it biases hip, knee and ankle flexion, which, like the squat, requires good amounts of eccentric lower limb control, which is an essential skill to have as a human mover.
One could add that, from a mental perspective, there is something special about running up a hill and reaching the top of it. There is a sense of accomplishment and satisfaction about moving forward and up, or reaching the top and looking down to where you came from.
How to Become Mentally Strong in Your Running Training
Dr. Francis continued that athletes, especially those who are suffering from an injury, should be consistent with their training.
He also said that people should stop boxing themselves in by, for example, identifying themselves as being a runner, rugby player or gymnast. Instead, we should all view ourselves broadly as being “athletes.” This opens up many new avenues for improvement, without feeling the pressure of having to always be super specialized and specific.
This is especially important during injury because… well, let’s say that someone identifies themselves exclusively as being a runner, but can’t run at a given time due to injury. Well, that person then loses their whole identity in one fell swoop, which is a lot to bear mentally. However, if this “runner” views himself as an athlete who cannot run for a while, then it still leaves him with many other possible ways to improve while his injury is healing.
Conclusion
Well, that concludes the summary of the interview with Dr. Francis.
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