Toes or Heels?  The Runner’s Debate

November 12, 2019 | Running

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Forefoot strike running can reduce impact forces on the leg, leading to a reduced risk of some types of running injuries
  • However, the transition from heel strike to forefoot strike running can be difficult, potentially leading to injury during the transition
  • In an interview with Michael Fredericson M.D., he does not see a clear performance benefit to forefoot running and did not recommend that successful heel strike runners make the transition to forefoot running

As an orthopedic surgeon I generally see folks in my clinical practice once something has gone wrong. Either they’ve been injured already or there is some ongoing reason that affects pain, performance, or quality of life. But in our role as team physicians we get a chance to interact with athletes before a problem has occurred.

I’ll often see athletes with Achilles tendinitis or shin splint syndrome and discover that they recently changed their running style from heel strike to forefoot strike. It’s easy for me to jump to the conclusion that forefoot running is somehow bad for runners. Or am I seeing a skewed population? I recently spoke with my Stanford colleague Michael Fredericson M.D., an internationally recognized running expert to find some answers.

Dr. Fredericson is a professor of orthopedic surgery at Stanford, and is the head team physician for Stanford’s intercollegiate track and field team. He’s also a team physician with USA Track and Field and US Olympic teams. He’s researched and published extensively on running mechanics and injuries. Here’s a brief Q and A that I did with Dr. Fredericson.

Q: Can you briefly explain “forefoot strike” running and its possible advantages?

A: Most distance runners make contact with the ground by striking their heel first, called heel strike running. A small percentage land with their foot flat, and an even smaller percentage land on the front portion of their foot, called “forefoot strike.” There are biomechanical studies showing that forefoot running can reduce impact forces on the leg, and theoretically lead to lower injury rates for some types of injuries.

Q: In your experience what percentage of runners are heel strikers versus forefoot strikers?

A: For recreational runners I would estimate that about 80% are heel strikers, about 15% midfoot strikers, and about 5% forefoot strikers. Interestingly at the international level, about half to two thirds are forefoot strikers.

Q: Is there a performance benefit to forefoot running?

A: No, I don’t think so.

Q: So the main benefit then is possible injury risk reduction? Are you aware of high-quality evidence about differences in injury rates of heel strike versus forefoot strike running?

A: Yes, there is some good evidence that conditions such as exertional compartment syndrome, patellar tendinitis, and possibly tibial stress injuries are reduced in forefoot strike runners. But the key is that you have to use perfect form and ramp up properly.

Q: Which brings us then to the question of problems with forefoot strike running. What are some of the problems you’ve seen in runners converting from heel strike to forefoot strike running?

A: Converting to forefoot strike from heel strike is not easy. The initial transition places increased strain on the medial gastroc muscle in the calf and medial tibia, which can lead to shin splint syndrome. And there’s also increased strain on the Achilles and other tendons which can lead to tendinitis. If you’re planning to make the switch you should do this very slowly and preferably under the guidance of an experienced coach.

Q: If a runner is successful as a heelstriker should she/he make the switch to forefoot running?

A: If it’s working for you I don’t see a compelling reason to change.

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