Does Footwear Change Injury Risk? Minimalist, Cushioned and Stability Shoes

A Question With Strong Opinions

Few topics in running attract firmer opinions than shoes. Minimalist shoes are promoted as more natural, cushioned shoes as protective, and stability or motion-control shoes as a way of correcting feet that roll inwards. Each claim sounds reasonable mechanically, but injury risk is shaped by many things at once, and a shoe is only one of them. The more useful question is whether shoe type has been shown to change how many runners actually get injured.

What the Randomised Trials Show

A Cochrane review of running shoes for preventing lower-limb running injuries pooled 12 trials with 11,240 participants, lasting from 6 to 26 weeks (Relph et al., 2022). Its overall conclusion was cautious: most comparisons between different types of running shoe showed no clear reduction in injuries, and the certainty of the evidence ranged from very low to low. Runners cannot be blinded to the shoes they are wearing, injury was defined differently from trial to trial, and for several comparisons (for example stability versus neutral shoes) only one small trial was available.

For neutral or cushioned shoes compared with minimalist shoes, the review found that they may make little or no difference to the number of runners injured, again with low-certainty evidence. The review also found no trials comparing running shoes with non-running shoes, so the broader question of whether running shoes protect at all remains unanswered by randomised evidence.

Does Matching the Shoe to the Foot Help?

A common practice is to assess the arch and prescribe a shoe accordingly, with stability features for flatter or more pronated feet. The Cochrane review found moderate-certainty evidence that prescribing shoes on the basis of static foot posture probably makes little or no difference to lower-limb running injuries, although all three trials in that comparison were in military recruits and the finding may not transfer neatly to recreational runners (Relph et al., 2022).

This fits with a large Danish cohort of 927 novice runners who all started in the same neutral shoe. Pronated feet were not associated with a higher risk of injury than neutral feet, and the authors noted that more work was needed to clarify the position for highly pronated feet (Nielsen et al., 2014). Foot posture appears to be, at most, a modest piece of the injury picture.

What This Means in Practice

Taken together, the evidence does not support strong claims that any one category of shoe prevents injury, or that a particular foot type needs a particular shoe. Training load, how quickly it changes, recovery and individual history probably matter at least as much, which is one reason load management features so heavily in running injury prevention.

It is reasonable to treat footwear choice as a personal and comfort-based decision, and to introduce a substantially different shoe gradually, since it changes how load is distributed through the foot and lower leg. Anyone with persistent foot, shin or knee pain, or a history of repeated running injuries, is better served by an individual assessment than by a general rule about shoes.