Citing better stability, improved shock absorbency and reduced force on metatarsophalangeal joints, this author says maximalist shoes have been beneficial for runners in his practice.
By Richard Blake, DPM
Maximalist shoes are characterized by big, cushiony and wide midsoles. You can look at an athletic shoe and if the midsole looks too big for the shoe, it is probably a maximalist version. Almost every shoe company has maximalist shoes in its shoe line and some shoe companies, like Hoka One One or Altra, only have this type of shoe.
Maximalist shoes arrived on the scene around 10 years ago and did not get much press. The barefoot running controversy had started and shoes with little soles were getting most of the publicity and fanfare. However, where maximalist shoes have survived the test of time, minimalist shoes are fading in popularity.
The maximalist shoes of today are more stable than their predecessor Masai Barefoot Technology (MBT) shoes. These shoes were cushioned but very unstable. The modern day maximalist shoe is more stable with similar eversion as neutral shoes and has so many options.1 These shoes are all more cushioned than the typical Brooks or New Balance athletic shoe. This protects runners from developing problems related to poor shock absorption.
Two big problems runners and walkers face are too much inconsistency with month to month workouts. We are starting over too often and our feet are subject to jarring forces as well as too much cement and asphalt in our workouts.
Podiatrists have developed incredible advances with functional foot orthotic devices. These devices have been part of the maximalist shoe approach. Throw as much cushion and support under an athlete, and he or she will be able to avoid overuse injuries to a great degree. The minimalist shoe camp shuns these wonderful orthotic devices as ruining the strength of our feet. The minimalist shoe advocates maintain that simply putting our patients on great foot and ankle strengthening programs typically is enough to offset any loss of strength.
Maximalist shoes enable athletes to run or walk without a change in their gait to a degree if they are forefoot or midfoot strikers. For some runners, the big heels of maximalist shoes increase stress at impact whereas others feel the amazing shock absorption.1
Why Maximalist Shoes Can Be Advantageous For Runners
The classic maximalist shoe is the Hoka One One shoe line. The thicker midsole with a 4 mm heel drop on average allows for a rocker effect across the ball of the foot. This is so helpful for many metatarsal problems since it eliminates the bend across the metatarsophalangeal joints. Runners just roll through the ball of the foot, decreasing the force to bend these joints at push-off. Running in maximalist shoes can help alleviate the pain with conditions and injuries like metatarsalgia, capsulitis, neuromas, sesamoid injuries and hallux limitus/rigidus symptoms.
One of the positives that came out of the barefoot running controversy was that running shoes had evolved with too high of a heel to forefoot drop. Thus, the heel was too elevated, causing instability issues and forcing the knees and hips to take more stress at impact. Minimalist shoes solved that by lowering the heel to forefoot ratio to zero. In other words, there was no heel drop. Maximalist shoes have also used that philosophy with 0- to 8 mm drops, especially in the whole line of shoes produced by Altra, which have zero heel drop.
It appears that the maximalist shoes were first adapted by the ultramarathoners, those athletes running more than a marathon of 26.2 miles and commonly up to 100 miles at a time. This group of individuals would not gravitate to a shoe with instability or poor shock absorption. However, one has to be selective since there is a range of shoes that are more or less stable, and more or less cushioned. Encourage your runner patients to work with your local shoe store staff who may be more familiar with this category of shoes.
Advising Your Patients On Maximalist Shoe Selection
As runners opt for soft, light and cushioned shoes, podiatrists should remind their runner patients that these shoes can also lose durability. One must research the quality or durability of a shoe at the running shoe store or online. Some of the earlier Hoka One One shoes only lasted for 100 to 150 miles of running and that would be totally unsatisfactory, especially when runners can get 500 to 800 miles of running in an average running shoe.
Minimalist shoes can also increase the stress at impact and overall pronation forces.2Minimalist shoes require that runners soften their gait by switching from a heel contact to a forefoot contact. This change, in itself, takes a lot of effort and, in some cases, is impossible to do correctly. Anyone who has worked with athletes knows it can take an entire college career, for example, to shorten someone’s stride and decrease vertical bounce. That being said, all podiatrists recommending maximalist shoes should also talk to the athletes about a softer midfoot (or full foot) land.
You also cannot forget about age. As athletes age, their bones get a little more brittle and there is more wear and tear on the joints. The added shock absorption from a maximalist shoe helps protect these structures. This should allow runners to exercise for many more years.
The Hoka One One is overall the most popular maximalist shoe but many other companies are making good inroads into the market so cherish the diversity. When advising my patients on maximalist shoes, I recommend they look for the following:
• stability for pronation or supination
• depth for orthotics (if the patient has orthotics or lifts for a short leg)
• maximal shock absorption at contact (good if you know the runner is a heel, midfoot or forefoot striker)
• forefoot rocker or ball of the foot bend
• extra narrow or wide in the forefoot
• zero heel drop or 4- to 8-mm drop
I feel the maximalist shoes have been a wonderful addition to my practice. They are stable, work well with orthotic devices, provide incredible shock absorption, allow variability for ball of foot bend or no bend, and some width variations. Runners and walkers should definitely have maximalist shoes in their closet to help with the stresses of workouts to prevent injuries. As with anything new, they should break these shoes in slowly.
Dr. Blake is a Past President of the American Academy of Podiatric Sports Medicine. He is in private practice in San Francisco.
To read Dr. Blake’s DPM Blog, go to https://www.podiatrytoday.com/blogs/richard-blake-dpm.
1. Pollard CD, Ter Har JA, Hannigan JJ, Norcross MF. Influence of maximal running shoes on biomechanics before and after a 5K run. Ortho J Sports Med. 2018;6(6):1–5.
2. Sinclair J. The influence of minimalistic and maximalistic footwear on the kinetics and kinematic of running. J Footwear Sci. 2016;8(1):33–9.
While there are far too many variables to definitively determine which footwear model will better support foot function in runners, this author says the combination of heel elevation and rigid toe spring in most maximalist running shoes promotes muscular atrophy and arch instability.
By Ray McClanahan, DPM
The short answer to whether minimalist shoes are better than maximalist shoes depends on too many variables to cover in a short Point-Counterpoint piece. The only way to be able to comment intelligently on this question would be if all maximalist shoes were the same, all minimalist shoes were the same, all surfaces were the same and all runners had the same gait and biomechanics.
Those of us who prescribe and run in minimalist shoes encountered this lack of uniformity and definition for minimal footwear. The Minimalist Index helps guide clinicians and athletes in an understanding of the vast differences in models of minimal footwear.1 Using the index allows us to compare weight, heel thickness, heel to toe drop, motion controlling/stability features and flexibility. Knowing these variables enables us to potentially match footwear to the unique attributes of each of our runners as well as assist them in avoiding injuries when they are transitioning between footwear.
In developing the Minimalist Index, the authors noted the following standard definition for minimalist shoes: “Footwear providing minimal interference with the natural movement of the foot due to its high flexibility, low heel to toe drop, weight and stack height, and the absence of motion control and stability devices.”1
If proponents of the new shoe industry fad of maximalism wish to compare maximal footwear to any other type of footwear, there will need to be a standard definition of maximal footwear and a method of comparing different models. This definition does not currently exist. As is the case with minimal footwear, there are stark differences among maximal models, rendering any generalized statements of little value.
Although the new maximal shoes are lighter, possess a higher stack height and some have less of a heel to toe drop, they are not much different from the conventional running shoes of the last 30 or so years. In regard to the role of maximalist shoes in injury prevention, research has not shown that pronation control elevated cushioned heeled (PCECH) running shoes provide protection from injury and clinicians tend to recommend these shoes from a theoretical perspective that lacks scientific proof.2–3
Key Considerations In Selecting Shoes That Support Foot Function During Running
I believe a better question for us to ask ourselves is: what are the characteristics of naturally healthy running feet and what footwear models (maximal or minimal) will support their function?
Natural running foot posture requires the heel to be level with all of the metatarsal heads and phalanges. This requires no drop from heel to toe (heel elevation) and no rigid toe spring. Most maximal running shoe models have heel elevation and rigid toe spring. Heel elevation shortens our posterior calf muscles and toe spring shortens our anterior calf muscles (long extensor muscles), and also shortens tendons.4 Collectively, these features overlengthen our plantar intrinsics beyond their proper length to tension relationship and promote muscular atrophy and arch instability.
In a study involving 10 healthy participants, Kelly and colleagues noted that more postural demand increases the activation of plantar intrinsic foot muscles.5 In a study of 20 shod runners transitioning to minimalist shoes, Chen and colleagues found runners showed a significant increase in intrinsic and extrinsic muscle volume in the foot and leg.6
A study by Johnson and colleagues focused on 18 patients running in Vibram FiveFingers minimalist shoes in comparison with 19 patients running in traditional running shoes.7 The authors found the size of runners’ intrinsic foot muscles is important in ensuring a safe transition to running in minimalist shoes with the authors advising intrinsic foot muscle strengthening.
The combination of heel elevation and rigid toe spring distally displaces a runner’s submetatarsal fat pad into the sulcus, rendering it ineffective. This is ultimately ironic as this leads to runners needing cushioning built into the footwear since they are not able to properly benefit from their own fat pads.
Another misfortune that runners endure with both maximal and minimal footwear is the fashion feature of tapered toe boxes that hold the distal tips of the runner’s toes in a triangular configuration. This feature promotes the formation of bunion, tailor’s bunion, loss of single leg balance, unnatural increases in pronation, intrinsic muscle atrophy, ingrown/black toenails, blisters, corns, calluses and a host of more proximal symptoms.
What Benefits Do Minimalist Shoes Offer?
In my clinical experience as well as the literature, truly natural minimal footwear benefits runners in the following ways:
• improved balance
• increased plantar intrinsic hypertrophy and strength
• decreased oxygen consumption correlated with decreased weight of the shoe
• reversal of bunions and tailor’s bunions
• improvements in performance for sprinting, jumping and cutting sports
• reduction in pronation as the great toes are able to assume their natural position in line with the first metatarsal instead of being abducted toward the second toe
Although it is important for us to discuss the merits of shoes with lots of cushioning and the benefits of shoes with very little cushioning, it is significantly more important for us to ask ourselves why we prescribe any type of running shoe that does not allow the toes to spread wider than the balls of the feet, which is our natural foot posture? Herein lies a significant contributor to many of the running injuries that present to our offices, the reversal of which can be found in restoring natural foot posture, which we generally only see today in unshod cultures or the feet of the newborn.
Dr. McClanahan is in private practice at Northwest Foot and Ankle in Portland, OR.
1. Esculier JF, Dubois B, Dionne CE, et al. A consensus definition and rating scale for minimalist shoes. J Foot Ankle Res. 2015; 8:42.
2. Richards CE, Magin PJ, Callister R. Is your prescription of distance running shoes evidence-based? Br J Sports Med. 2009;43(3):159-62.
3. Gallant JL, Pierrynowski MR. A theoretical perspective on running-related injuries. J Am Podiatr Med Assoc. 2014; 104(2):211–20.
4. Csapo R, Maganaris C, Seynnes O, Narici M. On muscle, tendon and high heels. J Exper Biol. 2010; 213(Pt 15):2582-8.
5. Kelly LA, Kuitunen S, Racinais S, Cresswell AG. Recruitment of the plantar intrinsic foot muscles with increasing postural demand. Clinical Biomechanics. 2012; 27(1):46-51.
6. Chen TL, Sze LK, Davis IS, Cheung RT. Effects of training in minimalist shoes on the intrinsic and extrinsic foot muscle volume. Clinical Biomechanics. 2016; 36:8-13.
7. Johnson A, Myrer J, Mitchell U, Hunter I, Ridge S. The effects of a transition to minimalist shoe running on intrinsic foot muscle size. Int J Sports Med. 2016; 37(2):154-8.
8. Robbins S, Gouw G, Hanna A. Running-related injury prevention through innate impact-moderating behavior. Med Sci Sports Exerc. 1989; 21(2):130-9.
9. Altman AR, Davis IS. Prospective comparison of running injuries between shod and barefoot runners. Br J Sports Med. 2016; 50(8):476.
10. Goldmann J, Sanno M, Willwacher S, Heinrich K, Brüggemann G. The potential of toe flexor muscles to enhance performance. J Sports Sci. 2013; 31(4):424-433.
11. Jung DY, Kim MH, Koh EK, et al. A comparison in the muscle activity of the abductor hallucis and the medial longitudinal arch angle during toe curl and short foot exercises. Phys Ther Sport. 2011; 12(1):30-35.
12. Moon D, Kim K, Lee S. Immediate effect of short-foot exercise on dynamic balance of subjects with excessively pronated feet. J Phys Ther Sci. 2014; 26(1):117-119.
13. Rao U, Joseph B. The influence of footwear on the prevalence of flat foot. A survey of 2300 children. J Bone Joint Surg Br. 1992; 74(4):525-7.
14. Cheung RT, Sze LK, Mok NW, Ng GY. Intrinsic foot muscle volume in experienced runners with and without chronic plantar fasciitis. J Sci Med Sport. 2016; 19(9):713-715.
15. Glasoe W. Treatment of progressive first metatarsophalangeal hallux valgus deformity: a biomechanically based muscle-strengthening approach. J Orthop Sport Phys Ther. 2016; 46(7):596-605.
16. Goldmann J, Sanno M, Willwacher S, Heinrich K, Brüggemann G. The potential of toe flexor muscles to enhance performance. J Sports Sci. 2013; 31(4):424-433.
17. Headlee DL, Leonard JL, Hart JM, et al. Fatigue of the plantar intrinsic foot muscles increases navicular drop. J Electromyog Kinesiol. 2008; 18(3):420-425.
18. McKeon P, Hertel J, Bramble D, Davis I. The foot core system: A new paradigm for understanding intrinsic foot muscle function. Br J Sports Med. 2014; 49(5):290.
For further reading, see “When Patients Ask About Barefoot Running And Minimalist Shoes” in the May 2013 issue of Podiatry Today, “A Closer Look At Minimalist Running Shoes” in the September 2012 issue or the January 2012 online-exclusive article “Tackling The 10 Myths Of Barefoot Running.”