Heel strike or forefoot: running footstrike made no difference to injury risk in 738 runners

Most people who run land on their heels, and for about fifteen years many of them have been told that this is a mistake. Coaches, therapists and a shelf of running books have argued that touching down on the front or middle of the foot is gentler on the body. A study of 738 runners, followed for a year, has now put that advice to a direct test and found no difference in who got hurt.

The research was led by Joseph Hamill of the University of Massachusetts Amherst with Daniel Jandacka and colleagues at the University of Ostrava in the Czech Republic, and was published in Medicine & Science in Sports & Exercise in September. It is a modest study, and only 147 of its runners were forefoot or midfoot strikers. What sets it apart is the order of events. Each runner’s landing was measured in a laboratory first, and injuries were counted afterward. Nearly all the earlier evidence worked the other way round.

What is a footstrike, and how did heel striking get a bad name?

Footstrike is the part of the foot that meets the ground first. A rearfoot strike lands on the heel. A forefoot strike lands on the ball of the foot, and a midfoot strike puts heel and ball down more or less together. Among people who run in cushioned shoes, heel-first is the norm. When researchers filmed an elite half marathon in Japan, rearfoot strike was observed in 74.9% of all analyzed runners, and that was among some of the fastest athletes in the world.

The case against it began in 2010. Daniel Lieberman’s laboratory at Harvard compared people who had grown up running barefoot with people who had always worn shoes, and reported in Nature that habitually shod runners mostly rear-foot strike while the barefoot runners tended to land further forward. Their measurements showed why that might matter: barefoot runners who fore-foot strike generate smaller collision forces than shod rear-foot strikers. The authors suggested a forward landing may protect the feet and lower limbs from some of the impact-related injuries that plague runners. That was a suggestion based on forces. Nobody had counted injuries.

Two years later the same group did count them, in a college cross-country team. Of the 52 runners studied, most were heel strikers, and going back through the team’s injury records, the heel strikers had approximately twice the rate of repetitive stress injuries. The figure was repeated widely as barefoot and minimal-shoe running took off. The paper itself was more careful. It was retrospective, meaning it looked backward at injuries that had already happened, and its authors wrote that this study does not test the causal bases for this general difference.

How the 738 runners were tracked for injury

The new analysis draws on a Czech project called Healthy Aging in the Industrial Environment, which put adult volunteers through a detailed set of assessments, including a running analysis in a biomechanics laboratory. The sub-sample of 1315 participants consisted of 738 runners, 307 women and 431 men, and the rest were non-runners.

From the laboratory recordings the team calculated each runner’s strike index, a measure of where along the sole the first contact falls. On that basis 591 were classed as rearfoot strikers and 147 as non-rearfoot strikers, a label that takes in both midfoot and forefoot landings. Four in five, in other words, were heel strikers.

Then came the follow-up. For a year the runners answered regular questionnaires, and in the paper’s description the running-related injury onset was derived from the weekly, self-initiated, and decreased activity questionnaires. A runner who cut back training because something hurt would be picked up, as would one who reported an injury directly.

Did heel striking raise injury risk?

It did not. The share of runners injured over the year was statistically indistinguishable in the two groups, and the same held when the researchers looked at each injury site in turn. A further statistical model showed no evidence of an association between footfall pattern and injury risk. The conclusion is stated without hedging: a runner’s footfall pattern neither increases nor decreases the probability of injury.

That is firmer than a study of this size strictly allows, but it agrees with what independent reviewers had already concluded from weaker evidence. In 2020 Laura Anderson and colleagues at La Trobe University in Australia examined 53 studies on the subject. They noted that many coaches and therapists promote landing off the heel with a belief that it can treat and prevent injury, and found that the support for this came from backward-looking studies alone. Studies prospectively comparing injury risk between strike patterns are lacking, they wrote, and so the relationship between strike pattern and injury risk could not be determined.

A second review a year later, from Dublin City University, reached the same verdict. Aoife Burke’s team found 13 studies and judged the ones blaming heel striking harshly: these studies were very low quality, with few participants and poor measurement. When footstrike was measured on a continuous scale instead of sorted into categories, only 1 of the 7 studies reported a significant relationship with injury. Their closing line was a request: more large-scale prospective studies are required. The Czech study is a sizeable answer to it.

Hamill has argued this position for years. In a 2017 review with Allison Gruber, Hamill concluded from the literature then available that switching to a midfoot or forefoot landing does not reduce the risk of running-related injuries. The new data support a view its lead author already held, which is a reason to want the result repeated by others.

Why a different footstrike moves load without removing it

The laboratory results that started the debate are not in dispute. Landing further forward does soften the first jolt through the leg. What has become clearer since is that the load goes somewhere else.

A Finnish experiment shows the trade plainly. Juha-Pekka Kulmala and colleagues at the University of Jyväskylä compared nineteen female athletes with a natural forefoot strike against nineteen matched heel strikers. The forefoot group had less stress at the joint behind the kneecap, which may reduce the risk of running-related knee injuries. They also had about a quarter more force passing through the Achilles tendon, and the authors warned that this may increase risk for ankle and foot injuries.

The Australian review found the same pattern across many studies: a forward landing lowers the rate at which the leg is loaded at impact and produces greater ankle and plantarflexor loading, the plantarflexors being the calf muscles that point the foot. If one style spares the knee and taxes the calf while the other does the reverse, similar overall injury totals are what one would expect.

What 147 forefoot runners and a year of injury reports leave open

The study’s weak point is the size of its smaller group. With 147 non-rearfoot strikers, a real but modest difference in injury rates could go undetected, and a difference confined to one injury, say Achilles trouble in forefoot runners or knee pain in heel strikers, would be harder still to see. Finding no difference in a group this size shows that any difference is unlikely to be large. It does not show that there is none.

Injuries were also reported by the runners, not examined by a clinician, and a year is a short stretch in a running life. The runners were recreational adults in one Czech region, so the result says little about elite athletes or people running barefoot or in minimal shoes, the group the original theory was about. And the study compared habits people already had. It did not test what happens when a heel striker deliberately switches, a change the 2020 review flagged as shifting load onto tissues that are not used to it.

For a runner with no injury the result is reassuring. Nothing here is a reason to change a landing that feels natural and is not causing trouble, in either direction. Pain that persists with running is a matter for a clinician who can examine it.

When landing was measured first and injuries were counted afterward, heel strikers were hurt no more often than anyone else.