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Introduction
With the recent interest in the world of barefoot running and minimalist running shoes, research regarding this topic is widely sought after.  Christopher McDougall�s 2009 book �Born to Run�ADDIN RW.CITE{{120 McDougall,Christopher 2009}}1 has also ignited a lot of interest with its description of various supporters of the �barefoot movement�.  These include tribes of people who run hundreds of miles a week barefoot and various barefoot folk heroes who have run sans shoes for years.  This book along with new research from Lieberman et al.,ADDIN RW.CITE{{21 Lieberman,Daniel 2010}}2 has many runners considering a switch to either barefoot or at least minimalist running shoes. 
 	The research conducted by Lieberman et al.ADDIN RW.CITE{{21 Lieberman,Daniel 2010}}2 has been groundbreaking as these authors investigated groups of people who have never been exposed to running shoes and compared them to runners in the United States, who are conditioned to wearing running shoes.  The study showed that barefoot runners typically run in a forefoot strike pattern, which revealed significantly less impact forces during the striking phase of running gait compared to standard shod runners.  Large impact forces have been linked to various overuse running injuries and many believe reducing impact forces will potentially remedy some of these injuries.ADDIN RW.CITE{{93 Cavanagh,PR. 1980; 119 Daoud,Adam 2012; 139 Goss,Donald 2012; 91 Hasegawa,Hiroshi 2007; 60 Hreljac,Alan 2004; 21 Lieberman,Daniel 2010; 148 Montgomery,LC. 1989; 153 Rixe 2012}}2-9 
	Relatively few injury surveillance studies exist involving barefoot running,ADDIN RW.CITE{{119 Daoud,Adam 2012; 130 Salzler,Matthew 2012}}4,10 and therefore, there is no concrete evidence to suggest that barefoot running can prevent overuse running injuries.  In one study, subjects that met surgical criteria for an exertional compartment release were put on a forefoot running program.  By the end of this program all subjects avoided surgery and decreased the compartmental pressures post-exertion.ADDIN RW.CITE{{127 Diebal,Angela 2012}}11 This is one example of the positive effects of barefoot running.  However, there are also negative characteristics associated with this trend.  Arguments propose that running barefoot leaves the foot exposed to the harsh terrain and various hazards that shoes normally protect from.  Also, it is believed that training barefoot can lead to excessive stress being placed on the metatarsal heads, causing stress fractures.ADDIN RW.CITE{{128 Giuliani,Jeffrey 2011; 139 Goss,Donald 2012}}5,121 Barefoot running has shown various adaptations to both tempo and kinematics, such as faster stride rate, shorter stride length, landing in a more plantarflexed position, and less total knee excursion.ADDIN RW.CITE{{58 Divert,C. 2005; 49 Hardin,Elizabeth 2004; 21 Lieberman,Daniel 2010; 125 Lohman,Everett 2011; 23 Squadrone,R. 2009}}2,13-16 With altered running mechanics and impact forces, barefoot runners may develop chronic foot and ankle adaptations compared to runners who use traditional running shoes.  Therefore, the purpose of this study was to compare foot and ankle characteristics between barefoot runners and shod runners.  It was hypothesized that barefoot runners would have more ankle dorsiflexion range of motion (ROM) compared to shod runners.  Also, navicular drop and rearfoot valgus angle were both expected to be less in the barefoot population.  
Methods
This cross-sectional cohort study investigated the differences that exist between barefoot and shod runners.  The independent variable was group (shod runners and barefoot/minimalist runners).  The dependent variables were ankle ROM, arch height, and calcaneal angle.  

Participants
Seven barefoot runners (males n=5, females, n=2, age=39.5�14.9years, height=172.7�8.3, mass=73.0�13.7 kg) volunteered to participate from a local area barefoot runners club to serve as the minimalist group. Eighteen matched control participants (8 male, 10 female, age=24.9�5.8 years, height=170.7�8.1 cm, mass=70.7�13.1 kg) were recruited from local area running clubs to serve as the shod group.  Inclusion criteria for both groups included: running a minimum of 10 miles a week (running either barefoot or shod depending on group) for at least 3 months, and being between the ages of 18-60 years old.  Participants were excluded if they had suffered any lower extremity injury within the past 3 months that required more than one week of time lost from running or had any history of lower extremity surgery.  Participants were also excluded if they wore any physician prescribed orthotic devices.  To be considered for the barefoot group, participants either had to run barefoot or with Vibram fivefinger� shoes.  Vibram 5-finger shoes have been the only scientifically validated running shoe to mimic the barefoot condition.12 Participants in the shod group had to run with traditional running shoes only.  Each participant was informed of the experimental risks of the study and signed an informed consent form prior to data collection as approved by the university�s institutional review board.
Procedures
	All participants attended one testing session.  The examiners were all certified athletic trainers with experience in collecting the desired measurements.  Different examiners were used to collect the measurements. The examiners were not blinded to the participant�s group.  
Ankle plantarflexion ROM was collected using a standard goniometer with the patient seated on a table with the knee straight.  The fulcrum of the goniometer was placed over the distal aspect of the lateral malleolus with the stationary arm aligned with the long axis of the fibula, and the movement arm parallel with the long axis of the 5th metatarsal.  Participants� ankles were moved passively into plantarflexion until the first point of resistance was felt and that angle was recorded.  Plantarflexion inter-rater reliability was found to be (ICC=.87; SEM=2.6�). 
Dorsiflexion ROM was measured in a weight bearing position with the knee both extended and flexed as described by Denegar et al.ADDIN RW.CITE{{164 Denegar,Craig 2002}}17  Both knee flexed and extended measurements were taken with the ankle in a subtalar neutral position.  This was done by the examiner palpating the medial and lateral sides of the dome of the talus and supinating and pronating the foot until the talar dome was evenly positioned between the examiner�s fingers.   Once subtalar neutral was established, the participant was asked to lunge forward with the non-test limb forward.  The test side knee remained in full extension and the participant was instructed to lean forward until the back of the heel started to lift off the ground or they began to move out of subtalar neutral.  The Pro 3600 digital inclinometer (Spi-Tronic, Garden Grove, CA) was placed just proximal to the lateral malleolus in alignment with the fibula to determine the angle between the lower limb and a vertical reference as determined by the inclinometer.  For the weight-bearing measurement with the knee flexed, the same procedures for finding subtalar neutral were used. The participant was asked to perform a forward lunge by flexing both the contralateral hip and knee joints.  The amount of dorsiflexion ROM was measured using the same digital inclinometer placement and the measurement was taken at the point in which the participant�s heel began to rise, could not proceed any further in the lunge, or moved out of subtalar neutral.  All ankle ROM measurements were taken three times with the average of the three trials used for data analysis.  Dorsiflexion with the knee straight inter-rater reliability was found to be (ICC=.95; SEM=1.5).  Dorsiflexion with the knee bent inter-rater reliability was calculated to be (ICC=.95; SEM=1.7�).   
Inversion and eversion ROM were measured with the participant seated, with the goniometer fulcrum situated over the talocrural joint line, centered between the malleoli.  The stationary arm was aligned with the long axis of the tibia and the movement arm was aligned with the long axis of the 2nd metatarsal.  The tibia and fibula were stabilized by the examiner while the participant was passively moved into inversion and eversion until first resistance was felt and the angle recorded.  Inversion inter-rater reliability was found to be (ICC=.67; SEM=4.6�).  Eversion inter-rater reliability was calculated to (ICC=.72; SEM=2.42).
Arch height was measured by measuring the distance between the navicular tuberosity and the ground in two positions, subtalar neutral and relaxed.  The examiner first marked the most prominent point of the navicular for a reference point with an ink pen.  The participants were asked to stand naturally in a bilateral stance while the examiner placed the foot in subtalar neutral using the same methods explained above.  Once in subtalar neutral, the distance between the navicular tuberosity and the floor was measured with a ruler.  The participants were then asked to march in place for 10 seconds to assume a natural weight bearing position.  The distance between the navicular tuberosity and the ground was again measured and recorded.  The height of the navicular tuberosity in the natural weight bearing stance was recorded three times, with the average being used for analysis.  Navicular drop was also recorded as a resultant of the average relaxed weight bearing stance measurement being subtracted from the subtalar neutral measurement.  ADDIN RW.CITE{{152 Vinicombe,A. 2001}}18  For the arch height measurement, inter-rater reliability was found to be (ICC=.84; SEM=0.3cm).  
To measure calcaneal angle, the examiner marked lines bisecting the lower 1/3 of the Achilles tendon and the calcaneus on the participant while in a prone position. The participant was asked to step onto a 20 cm tall box and the foot was placed into subtalar neutral. The examiner then measured and recorded the angle between the two previously marked lines with the goniometer fulcrum on the superior calcaneus.  Participants were then asked to march in place for 10 seconds then immediately assumed a natural weight bearing stance while the measurement was repeated.  The natural weight bearing stance measurement was taken three times, with the average being used for reporting.ADDIN RW.CITE{{162 Donatelli,R. 1999}}19 A measurement of 0( indicated a neutral calcaneal angle.  A positive value indicated an everted calcaneus and a negative value indicated an inverted calcaneus.  This calcaneal angle measurement was found to have an inter-rater reliability of (ICC=.92; SEM=0.9�).

Statistical Analysis
Independent samples t-tests were performed to determine if differences existed in the clinical variables between shod and barefoot runners. Dependent variables were each ankle ROM measurement (dorsiflexion, plantarflexion, eversion, inversion), arch height, and rearfoot angle. The independent variable was group (barefoot runners, shod runners).   Because multiple tests were run we used a Bonferroni correction to control for Type I error (p< 0.05/11, p<0.005).   
Results
Participant�s running demographic data is shown in Table 1. No significant differences were found for height, mass, or age between groups (p>0.10).  Also, no significant differences were found between groups regarding weekly mileage or barefoot experience (p>0.20).  Means and standard deviations for all ankle and foot measurements among both groups can be viewed in Table 2.  No significant differences in calcaneal angle were found between shod (4.0�5.3�) and barefoot (8.5�4.3�) runners (p=0.04) with both groups in an everted position. No significant difference in the change in rear foot angle from a subtalar neutral position into weight bearing was also found between shod (1.0�2.8�) and barefoot (4.8�5.3�) runners (p=0.03). No significant findings were found regarding navicular height in subtalar neutral or natural stance; or navicular drop between groups (p>0.07). Also, no significant differences between groups were found for dorsiflexion in a flexed or extended position, inversion, or eversion ankle ranges of motion. (p>0.11).  



Table 1.  Group Running Experience and Mileage Variables 
VariableBarefoot ShodBothRunning Experience (years)11.0�11.47.2�4.58.3�7.1Barefoot Running Experience(years)2.0�1.0N/AN/ARunning Miles (miles/week)28.8�19.220.4�12.222.8�14.7










Table 2.  Comparison of Ankle and Foot Characteristics between Groups.
VariableBarefootShodpValueRearfoot Angle (Subtalar Neutral)3.7�2.7�3.3�3.2�0.79Rearfoot Angle (natural stance)8.5�4.3�4.0�5.3�0.04Change in Rearfoot angle4.8�5.3�1.0�2.8�0.03Navicular Height (Subtalar Neutral)4.6�0.4cm4.2�0.7cm0.13Navicular Height (natural stance)4.2�0.4cm3.8�0.6cm0.07Navicular Drop0.4�0.3cm0.3�0.2cm0.22Plantarflexion ROM55.5�10.7�53.8�5.5�0.69Inversion ROM32.4�4.9�34.3�8.9�0.60Eversion ROM17.9�2.8�14.7�4.9�0.11Dorsiflexion ROM (knee flexed)41.8�8.2�40.7�7.4�0.74Dorsiflexion ROM (knee extended)33.9�7.3�34.5�6.4�0.84ROM=range of motion.


Discussion

The purpose of this study was to compare foot and ankle characteristics between habitually barefoot and shod runners.  No previous research has investigated how running barefoot may affect ankle ROM, arch height and drop or calcaneal angle.  Therefore, our results are the first to show that there are no differences in these variables between barefoot and shod runners.  These findings provide researchers useful information in the prevention, examination, and treatment of injuries associated with habitual barefoot running.  
	Our study found no significant differences in dorsiflexion ROM between the barefoot and shod groups.  This ROM has clinical indications as dorsiflexion has been found to be a determining factor for injuries.20 Barefoot runners typically experience a large amount of ankle plantarflexion and dorsiflexion ROM as a result of using a forefoot strike.5,13  Because forefoot strikers land in a plantarflexed position as opposed to a dorsiflexed position, typical of a rearfoot striker,ADDIN RW.CITE{{193 Altman,Allison 2012; 137 Bennett,Jason 2012; 21 Lieberman,Daniel 2010}}2,20,21 we hypothesized the barefoot runners would subsequently have more tonicity of the triceps surae muscle group, thereby decreasing their dorsiflexion ROM.  However, our results did not support this hypothesis.  Furthermore, we hypothesized there would be no difference in any other ankle ROM (plantarflexion, eversion, and inversion).                                                                                                                                                                                                                      	Although pronation and supination occur at different points during running when using a forefoot versus a rearfoot strike, they still occur.  Research has shown that although standard running shoes limit the foot�s ROM, they do not inhibit the motion of the ankle joint as significantly.ADDIN RW.CITE{{22 Morio,Cdric 2009}}22 Although research has determined that barefoot runners typically land in more of a plantarflexed positionADDIN RW.CITE{{12 Jungers,William 2010}}23, little evidence has shown differences in motion occurring in the frontal plane.ADDIN RW.CITE{{193 Altman,Allison 2012; 12 Jungers,William 2010; 22 Morio,Cdric 2009}}20,22,23
	Navicular drop can give researchers insight regarding a runner�s amount of pronation and forefoot angles.ADDIN RW.CITE{{208 Buchanan,Kirsten 2005; 207 Mueller,MJ. 1993}}24,25 We hypothesized that barefoot runners would have less navicular drop than shod runners.  This hypothesis was based on the theory that barefoot runners would have greater intrinsic foot musculature strength since the foot is free to move without the constraints of modern running shoes and does not rely on the medial arch post and other shoe supports; thereby, forcing the foot to rely on its own neuromuscular system to control forefoot movement.  Therefore, we believed the arch would be more intrinsically supported and therefore drop less.  However, our results showed no differences between groups.  This may suggest that rigidity could be inherent in the medial arch of shod runners since they often run hundreds of miles with the aid of this post within their shoes resulting in less navicular drop.  
	No significant differences were found between groups in the calcaneal angles measured while weight bearing in a relaxed position or the change in calcaneal angle from weight bearing subtalar neutral to a relaxed stance.  Both groups were predominantly in calcaneal eversion.  This is a very common angle observed among many individuals, regardless of running experience or type, in a bi-pedal stance.ADDIN RW.CITE{{205 Kirby,KevinA 2000}}26  This measurement gives insight into how much pronation the foot can experience when moving from a neutral to a weight bearing position. Previous researchers have shown pronation to be essential to any running style, regardless of strike type.ADDIN RW.CITE{{90 Adelaar,RS. 1986; 12 Jungers,William 2010}}23,27  Morio et al.,ADDIN RW.CITE{{22 Morio,Cdric 2009}}22 discussed how modern running shoes include a medial post which can severely restrict the amount of pronation the foot can undergo during running.  Pronation allows an unlocking mechanism to take place among the tarsal and metatarsal bones which allows the foot to conform to the terrain.ADDIN RW.CITE{{90 Adelaar,RS. 1986; 86 Chan,CW. 1994; 9 Czerniecki,JM. 1988}}27-29  Based on our results both barefoot and shod runners have similar calcaneal eversion angles while weight bearing.  
	Two reasons why our barefoot runners did not present with any foot or ankle adaptations compared to the shod runners may have been due to their preferred style of running gait and their limited amount of barefoot running experience.  Lieberman�sADDIN RW.CITE{{21 Lieberman,Daniel 2010}}2 research suggests that the vast majority of habitual barefoot runners forefoot strike and shod runners rearfoot strike, yet, we cannot assume that the barefoot participants in our study were all forefoot strikers.  Also, Lieberman�s2 study was conducted on runners who grew up in the barefoot condition while our study included runners who had been running barefoot for an average of only 2 years.  Even though some of our participants had been running barefoot longer, it is possible that 2 years is not enough time to develop any anatomical adaptations to the barefoot running style.  A study repeated on runners with more barefoot experience may yield different results.
	A major limitation of this study is our low sample size of habitually barefoot runners.  With only seven barefoot runners, it is difficult to generalize our results or make any definitive conclusions. A power analysis revealed that to find significance for the variable of navicular height in a subtalar neutral position, 26 participants per groups were necessary to find significance at an alpha level of 0.05 with a power of 0.80.  However, based on our inclusion and exclusion criteria we were unable to identify and recruit enough barefoot runners. 
Conclusion
	Our results suggest that barefoot runners do not undergo any anatomical adaptations as compared to shod runners.  While the results of this study show promise, it is essential that future research be completed with a larger sample prior to making conclusions. Future research should be conducted involving both static and dynamic variables involving the foot as well as in participants with more barefoot running experience.  Information regarding these topics could give runners and clinicians insight into various foot pathologies that may be related to a runner�s choice in footwear.ADDIN RW.CITE{{142 Wen,DY. 1997}}30



















REFERENCES

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12. Giuliani J, Masini B, Alitz C, Owens B. Barefoot-simulating footwear associated with metatarsal stress injury in 2 runners. Orthopedics. 2011;34(7):e320-e323.
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