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ORIGINAL ARTICLE
Year : 2018  |  Volume : 18  |  Issue : 3  |  Page : 136-145

Screening of foot defects, deformities, and diseases among endurance runners: A cross-sectional study


1 Department of Physiotherapy, Alva's Education Foundation, Dakshina Kannada, Karnataka, India
2 Department of Dermatology, Derma Care, Mangalore, Karnataka, India

Date of Web Publication6-Nov-2019

Correspondence Address:
Watson Arulsiingh DR
Department of Physiotherapy, Alva's Education Foundation, Moodubidire, Dakshina Kannada, Karnataka
India
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DOI: 10.4103/sjsm.sjsm_36_17

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  Abstract 


Design: This is a cross-sectional study.
Background: There was not a study in the past which exclusively defines and reports foot defects, deformities, and diseases among barefoot and shod endurance runners.
Methods: Participants were added by snowball sampling method after fulfilling inclusion criteria as barefoot runners (n = 80), shod runners (n = 80), and healthy collegiate nonrunners (controls n = 80) from Dakshina Karnataka, India.
Outcome Measures: Foot deformities, foot defects, and diseases were identified using valid tools.
Results: All foot defects, deformities, and diseases for three groups were identified and analyzed by one-way ANOVA which revealed a significant difference in the foot defects, deformities, and diseases (P < 0.01). Type of running, duration of running, and foot type were associated with the foot defects, deformities, and diseases in each group at 95% confidence interval.
Conclusion: This study concluded that there exists a significant difference in foot defects, deformities, and diseases between three groups and found a strong association between specific type of running, duration of running, and foot type with the foot defects, deformities, and diseases. Hence, this study alarms runners, coaches, and shoe manufacturers to work on strategies to prevent all foot problems reported among runners.

Keywords: Barefoot, blister, calluses, corn, jogger's toe, plantar warts, subungual hematoma


How to cite this article:
Arulsiingh DR W, Pai GS. Screening of foot defects, deformities, and diseases among endurance runners: A cross-sectional study. Saudi J Sports Med 2018;18:136-45

How to cite this URL:
Arulsiingh DR W, Pai GS. Screening of foot defects, deformities, and diseases among endurance runners: A cross-sectional study. Saudi J Sports Med [serial online] 2018 [cited 2019 Nov 18];18:136-45. Available from: http://www.sjosm.org/text.asp?2018/18/3/136/270321








  Introduction Top


Running is a popular form of exercise that people engage in to stay active and healthy. However, owing to a high incidence of runners' injuries, there arises a need to increase safety of running so as to derive the health benefits of running that overweigh the risk of injury.[1] Though researchers explore to understand the biomechanical variation of shod running from barefoot running, no evidences are available to state that barefoot running is better than shod running in preventing runner's injuries.

Moreover, it is clear that running shoe cannot completely bring about the working biomechanics of barefoot running. Foot problems are the most common injuries that are reported by long-distance runners. A previous study concluded that runner's shoes with arch supports and stiffened soles have negative impact on weakening foot muscles and arch and cause excessive pronation to place strain on the plantar fascia and lead to plantar fasciitis.[2]

Kouchi et al.[3],[4] reported significant morphological changes in feet of runners and nonathletes. Others [5],[6] claimed that bare footers do acquire very few foot defects. Researchers blamed that shoes do not always match the foot in regard to fit due to irregular fit of different lengths and widths, variations of the anatomical positioning of pedal soft tissue, and osseous structures that may alter the morphology and biomechanics of the foot.[7]

Blisters, jogger's toe, calluses and corns, subungual hematoma,[8],[9] macerated web spaces, plantar warts, and irritant dermatitis are fungal, bacterial foot infections, Talon noire or “black heel,” heel fissure,[9] tineapedis, onychomadesis, calcaneal petechiae, nail disorders [10] pitted keratolysis and folliculitis, athlete's nodules, jogger's itch, callosities, and talon noir were all common foot problems reported among marathon runners in European countries.[11] Other researchers [12],[13] from the USA reported unshod populations to have a lower percentage of pes planus and a lower frequency of foot abnormalities. Despite these foot problems among endurance runners, none threw insight into determining whether these foot disorders are more among barefoot runners or shod runners.

Barefoot running is an emerging trend, despite a subject of much controversy. Up-to-date, benefits of barefoot running appear to be more speculative and anecdotal than evidence based.[1] Additionally, associations of various factors causing runner's injuries were not well established.

Though little evidence of foot deformities, defects, and disease on healthy, elderly, diabetic populations are available, up-to-date, there is not a study in India which exclusively reports foot defects, deformities, and diseases among barefoot and shod endurance runners.

Research question 1

Are there any difference in the existence of foot defects, deformities, and diseases among barefoot and shod runners?

Research question 2

Are there any association between duration of running, type of running, and foot type to the development of foot defects, deformities, and diseases in shod runners and barefoot middle- and long-distance runners?


  Methods Top


Design

This is a cross-sectional study.

Participants

The study participants included barefoot runners (n = 80), shod runners (n = 80), and healthy collegiate nonrunners (controls, n = 80) from Dakshina Kannada, India.

This was carried out on middle- and long-distance shod and barefoot runners and nonathletic participants of Dakshina Kannada by snowball sampling method.

Adult long- and middle-distance shod and barefoot runners who run ≥30 km/week and also participated in running for a minimum of 3 years' duration with an age range of 18–55 years participated in this study. Both females and males were included. Healthy collegiate students had represented control group.

Runners were excluded if he or she had congenital deformities of foot, trauma in the feet other than sports related, athlete with auto-immune disorder, runner with metabolic diseases, smokers, runners with minimalist foot wear, had a history of or suspicious of diabetes, participant with suspected or known cardiac problem, gout patients, and any other neurologically affected foot.

Sample size fixation

A total sample of 255 was targeted at 5% dropout by conforming to the sample size of 240. For this purpose, 240 were elected out of 265 individuals who were screened in which 80 were barefoot runners and 80 were shod runners and other 80 were healthy nonrunner (controls) counterparts. Ethical committee approval was obtained before the start of the study. Purpose of the study was explained to each candidate. Informed consent was obtained for experimentation with human subjects. The privacy rights of human subjects must always be observed. Participant's each foot was evaluated to screen the deformities, defects, and diseases.

Materials used

Stadiometer, vernier caliper, weighing scale, goniometer ruler, custom-made Brannock ® style device, life size photographs of various foot disease and defects, color ink, graph sheet, pencil, 16.1 Mega pixel camera (Sony) with ×10 optical zoom, foot wear type picture chart, and shoe motion control property scale were used [Figure 1].
Figure 1: Materials utilized for this study

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Procedure for screening

Participant's each foot was evaluated to screen the deformities, defects, and diseases under the following methods and outcome measures.

To screen hallux valgus deformity,[14],[15] Life-size versions of the four photographs of grading of hallux valgus deformities were used. Students were asked to stand on an elevated platform and were instructed to walk in place for a few steps and then stand in a relaxed position. Validated Life size photographs [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d were kept alongside participants in standing position, and then hallux valgus deformity was identified.
Figure 2: (a-d) Life size photographs of hallux valgus

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Screening Hallux rigidus [16] was based on range of motion of the first metatarsophalangeal (MTP) joint measured with goniometer with the foot in plantigrade position, Hallux rigidus was identified as directed by Coughlin and Shurnas and conformed by orthopedic surgeon [Figure 3].
Figure 3: Depiction of how great toe extension was measured with goniometer ruler

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Forefoot and rear foot varus and valgus were screened as per the guidelines proposed by Buchanan et al.[17],[18],[19],[20] [Figure 4]. If positive degree was found, that was labeled as forefoot varus, labeled as neutral if it is 0°, and if negative degree was found, that was labeled as forefoot valgus.
Figure 4: Depiction of how forefoot varus/valgus was measured and screened

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After the subtalar neutral position was determined, calcaneal tilt angle was measured. If calcaneal angle [Figure 5]a, [Figure 5]b, [Figure 5]c, [Figure 5]d, [Figure 5]e was more than 6° from neutral on either side, it was considered as rear foot varus and valgus deformity, respectively.
Figure 5: (a) Depiction of how midpoint of calf measured with vernier caliper. (b) how midpoint of distal calf was measured. (c) how midpoint of distal calf was measured. (d) how midpoint of lower calcaneum was fixed with tape. (e) how calcaneal tilt was measured with goniometer ruler

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Screening flat foot

According to Murley et al.[21] [Figure 6]a and [Figure 6]b, truncated foot length was measured as the perpendicular distance from the first MTP joint to the most posterior aspect of heel. Then, navicular height was divided by truncated foot length to derive truncated navicular height using foot prints. If values fall between 0.22 and 0.31, it was considered as normal arch of foot. If values were >0.18, it was documented as flat foot.
Figure 6: (a) Depiction of how navicular tuberosity was identified. (b) how truncated navicular height was measured with footprint

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Screening various foot defects, deformities, and disease

Standardized photographs of various diseases and defects of foot approved by the dermatologist [22],[23],[24] were used to screen foot disorder. Corns, calluses, and verrucas were screened as per the criteria.[25],[26] Evaluation of the shoe [27] was carried out with the validated tool developed by Barton et al. in 2009.

Data analysis

Sample size was fixed (95% significance) at 80% power with 30% risk of developing foot defects, deformities, and diseases in students only allowing 5% dropout through pilot study.

Descriptive data of demographic variables were generated. Mean foot defects, deformities, and diseases for three groups were analyzed using one-way ANOVA analysis.


  Results Top


Principal evaluator alone collected all the required samples from Alva's institution and Dakshina Kannada during the year 2009 to 2015 by visiting various colleges and attending all state, University level competitions.

Descriptive characteristics of participants in each group are provided in [Table 1]. The mean age of barefoot runner group was 20.68 ± 2.0, shod runners was 21.51 ± 8.2, and controls was 19.09 ± 3.1, who were screened in this study. The mean body mass index of barefoot runner group was 20.98 ± 2.5, shod runners was 19.86 ± 3.2, and controls was 18.74 ± 2.6. Mean distance run by barefoot runners per week was 81.87 ± 4.99 km and mean distance run by shod runners per week was 65.93 ± 24.14 km. Mean duration of shod runners was 5.35 ± 2.95 years. Mean duration of barefoot runners was 5.71 ± 2.46 years. [Figure 7], [Figure 8], [Figure 9], [Figure 10] illustrate the percentage of running type and foot type across groups. Descriptive data of mean foot defects, deformities, and diseases for three groups are summarized in [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15], [Table 16], [Table 17], [Table 18], [Table 19], [Table 20] with significance by one way anova analysis. Type of running, duration of participation, and type of foot were associated with the development of foot defects, deformities, and diseases in shod runners' group and barefoot runners' group.
Table 1: Descriptive statistics of demographic variables of samples

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Figure 7: The percentage of long- and middle-distance runners in barefoot runners' group

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Figure 8: The percentage of long- and middle-distance runners in shod runners' group

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Figure 9: Types of foot in percentage within barefoot runners' group

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Figure 10: Types of foot in percentage within shod runners' group

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Table 2: Mean number of subjective symptoms reported across three groups with P value

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Table 3: Mean number of hallux valgus across three groups with P value

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Table 4: Presence number of of mean corn across three groups with P value

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Table 5: Mean number of black toe across three groups with P value

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Table 6: Mean number of heel fissure across three groups with P value

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Table 7: Mean number of ingrown toe nail across three groups with P value

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Table 8: Mean number of plantar warts across three groups with P value

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Table 9: Mean number of fungal infection across three groups with P value

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Table 10: Mean number of callus across three groups with P value

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Table 11: Mean number of flat foot across three groups with P value

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Table 12: Mean number of forefoot varus/valgus deformities across three groups with P value

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Table 13: Mean number of calcaneal varus/valgus deformities across three groups with i value

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Table 14: Mean number of hallux varus across three groups with P value

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Table 15: Mean number of calcaneal prominence across three groups with P value

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Table 16: Mean number of thick toe nail across three groups with P value

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Table 17: Mean bunion across three groups with P value

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Table 18: Mean black heel across three groups with P value

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Table 19: Mean pitted keratolysis across three groups with P value

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Table 20: Mean blisters across three groups with P value

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Research question 1 (reporting of foot disorders across three groups)

Symptoms reported by runners

The current study reported equal existence of calcaneal pain, calf pain, and plantar fasciitis in both barefoot runners' and shod runners' groups.

Hallux valgus

The current study reported more number of hallux valgus in shod runners' group against barefoot runners and controls.

Ingrown toe nail, thick toe nail, and bunions

The current study reported more number of ingrown toe nail, thick toe nail, and bunion deformity in shod runners' group against barefoot runners and controls.

Callus

The current study reported more number of callus in shod runners' group against barefoot runners and controls.

Corn

The current study reported the shod runners to be affected with corn more than other groups.

Black toe, fore foot, calcaneal varus, valgus deformity, and calcaneal prominence

The current study reported more number of forefoot varus, valgus deformities and calcaneal varus, valgus deformities and black toe, and calcaneal prominence in shod runners compared to other groups.

Flatfoot

The current study reported more number of flatfoot found among shod runners compared to other groups.

Black heel

The current study reported more number of black heel among shod runners compared to other groups.

Fungal infection

The current study reported more number of fungal infections in foot among shod runners compared to other groups.

Hallux varus

The current study reported more number of hallux varus among barefoot runners against other groups.

Heel fissures

The current study reported more number of heel fissures among barefoot runners against other groups.

Plantar warts

The current study reported more number of plantar warts among barefoot runners compared to other groups.

Pitted keratolysis

The current study reported more number of pitted keratolysis among barefoot runners compared to other groups.

Blisters

The current study reported equal number of blisters among barefoot and shod runners which was not found in controls.

Research question 2

This current study found long-distance runners to have 1.46 times of developing hallux valgus, 4.69 times of developing corn, 2.25 times of odds risk in developing flatfoot over middle-distance runners in shod runner group, and exhibited a strong association with running distance to foot disorders.

Associating duration of running to foot problems

Shod runners' group

Participants with duration of running >5 years had shown 2.2 times of odds risk in developing black toe over who run <5 years' duration of running, and duration of running had shown a good association with these foot disorders.

Barefoot runners' group

Barefoot runners with <5 years' duration of running had 1.8 times of odds risk ratio over who have >5 years' duration of running in developing of blister in feet.

Association of foot type to foot problems

Shod runners' group

Runners with Egyptian foot had 2.1 times of odds risk in developing calcaneal deformity over Greek foot in shod runners' group, whereas square foot had 5.2 times of odds risk in developing callus in feet and 4.2 times of odds risk in developing calcaneal deformity over Egyptian foot in shod runners in the feet.

The current study found square foot to have 5.4 times of risk in developing callus and 8 times of odds risk in developing corn in feet over Greek foot in shod runners in shod runners' feet.

Barefoot runners' group

The current study reported Greek foot to have 2.1 times of odds risk over Egyptian foot in developing blister in barefoot runners' feet and square foot exhibited 3.3 times of odds risk over Greek foot in developing heel fissure in barefoot runners.


  Discussion Top


The results of this study demonstrated that shod long-distance runners had more number of foot defects, deformities, and diseases compared to barefoot runners in whom there were only few foot problems. Negligible foot disorders were reported among control group. This is the first cross-sectional study which classified long-distance runners into shod and barefoot running for the purpose of screening foot disorders existing among them. Though few surveys in the past reported the existence of foot disease among marathon runners from European countries, none have differentiated their frequency among shod and barefoot runners. Though ill-fitted shoes were blamed for the frequent occurrence of callus, corn, blisters, ingrown toe nail and black heel, toes and deformities among the shod runners, none have explored such existence of foot disorders among barefoot runners. This study finds equal number of foot symptoms reported among shod and unshod runners which is contrary to previous findings.[28-30]

Previous studies reported of existence of hallux valgus,[31],[32],[33],[34],[35] callus,[36],[37],[38],[39] corn,[36],[37],[38] collapsed foot arch [12],[40] and black heel,[29] and fungal infection [41],[42],[43] among shod runners yet not in the light of unshod runners and controls as of current study.

Joseph et al. reported hallux varus incidence among those who walk barefoot.[44] Another study reported pitted keratolysis among shod runners [9] and another reported occurrence of blisters in foot among marathon runners.[29],[45] Yet all these are not explored in the light of unshod runners and controls as of current study.

Previous study explained some association between running distance and foot infection.[45] Cowley and Marsden [46] reported that longdistance running has lowered foot arch immediately after marathon run on a shortterm basis. Few studies in the past reported no association between foot type to foot disorders.[47],[48] However, others explained some association between these variables.[49],[50],[51],[52],[53]

The current study shows foot problems of barefoot running against shod running. Foot problem present in barefoot running are quit fewer than shod running from the finding of present study. The endurance runners in Dakshina Kannada usually run on muddy ground as well as on road for their regular practice. Running barefoot cannot be completely recommended as broken glass or pieces of metal, animal excretes, and pebbles may be found on roadside, and until all the overall beneficial effects are proven. Hence, the emerging trend of minimalist running shoe can be an option until full light is shed on addressing foot problems that were reported with shod running and barefoot running.

One of the limiting factors that could not be controlled in this study was all runners in shod runner group had owned more than one shoes and used them alternatively for practice competition. Runner's shoe brand was not recorded. Hence, shoe characteristics could not be associated with the foot disorders.

Future study can associate foot defects, deformities, and diseases with across various types of minimalist running shoe and shod runner group with their brands as longitudinal design.

This study concluded that there exists a significant difference in foot defects, deformities, and diseases between three groups, of which shod runners had more foot defects, deformities, and diseases compared to barefoot runners and found a strong association between the type of running, duration of running, and foot type with the foot defects, deformities, and diseases. Hence, this study alarms runners, coaches, and shoe manufacturers to work on strategies to Prevent all foot problems reported among runners.

Declaration of patient consent

The authors certify that they have obtained all appropriate participants consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The participants understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors express sincere thanks to Professor Radhakrishna, Physical education director, Alva's education foundation, for his contribution toward sample collection and all participants for their cooperation and referrals.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15], [Table 16], [Table 17], [Table 18], [Table 19], [Table 20]



 

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