Introduction

Footwear has a powerful influence on our foot and ankle function, healing, and optimization of our walking. It’s such a simple thing to modify, that can also make huge improvements. But if we’re going to really get into this, we need some context first. So first I’ll discuss normal movements of the foot during walking gait, then address some myths about footwear and the gait cycle. Finally, I’ll provide my recommendations for types of footwear for the general population, with some nuance for people with certain medical diagnoses. As a disclaimer – this is a general informational blog and is NOT medical advice, please ask your local physical therapist what shoes are right for your exact situation. Additionally, I will mostly be discussing walking here, more than running.
Let’s go!

Part 1: Normal Movement of a Healthy Foot and Ankle During Walking

Early stance

• We’re meant to land on our heel first when we walk. Our heel bone (the calcaneus) has a somewhat unique bony structure that makes it better able to disperse the impact of our foot accelerating into the floor with all of our bodyweight. Between the heel bone and the skin on the bottom of the foot is a very well designed fat pad – imagine cells of fat separated by tough connective tissue, which is also extremely effective at distributing the force of our landing. This is our built-in cushion.

• After landing on the heel, the rest of the foot lowers to the floor with control from the muscles on the front of the shin, so it’s set down gently. This muscle action also pulls the shin forward, helping us transition our weight smoothly onto this foot.

• As weight is shifted onto this foot, the foot pronates – the arch lowers. Because of the anatomy of this part of our foot, when the foot pronates, it becomes looser and more adaptable. This makes it easy to adapt to whatever surface the foot encounters – part of why healthy people can step from pavement to soft grass without looking down and without having a balance problem.

Muscles on the right and left sides of the ankle contract together, so that the arch is also set down at a controlled pace, and the two muscles and their tendons form a stirrup of stability protecting both sides of the ankle. As weight shifts onto this foot, the front of the foot splays – the toes and the bones leading up to the toes (metatarsals) naturally spreading out a bit. This makes the front of the foot wider, making it easier to balance.

Middle to late stance

• As the shin continues rocking forwards over the foot, tendons in the back and inside of the ankle (achilles and posterior tibialis), are storing elastic energy (think of stretching a rubber band.)

• Bodyweight keeps shifting forward, and before putting the other foot down, the heel leaves the floor. The posterior tibialis tendon recoils, so that elastic energy as well as some active muscle contraction from this built in arch supporting muscle moves the arch to a higher arch (supinated) position. Because of the anatomy of the foot bones, this supinated position locks the middle of the foot, making it a rigid lever – exactly what you would want to propel off of.

• At the same time, when the heel leaves the ground, the small muscles within the foot (the foot intrinsic muscles), are active, supporting the arch (contributing to that beneficially stable position at this phase) and somewhat offloading the plantar fascia. The plantar fascia is connected to the achilles tendon. At this point, when all the weight is on the ball of this one foot, the shin is the most tipped forward and the toes are in an extended (bent up) position. So the calf muscle, the tendon, and the plantar fascia are all lengthened, storing a lot of elastic energy. The pressure in the bottom of the foot moves toward the big toe, since this toe and joint are so much larger than the others and well designed to deal with all that force.

Swing phase

• As the other foot touches down in front of the body and one starts to shift weight forward onto that foot, the standing foot behind the body can finally release all that tension built up in the plantar fascia and achilles tendon. This pops that heel up, but the ball of the foot stays in contact with the floor an instant longer (placing the toes in extension or bent back.) That shoots the knee forward as the shin rocks forward over the ball of the foot – starting the swinging phase without using any muscle energy. This also means that if the pelvis and hip are moving correctly, one achieves even more of the movement of swinging the leg forward for “free” – not requiring the hip and thigh muscles to work. This is great because it means humans can walk much further. We wouldn’t be capable as a species of feats like ultramarathons if every part of our gait only occurred because of active muscle use. Our bodies work smarter, not harder.

• While the foot is in the air, the muscles that extend the toes and help to clear foot work together with hip and knee muscles to prevent tripping, and prepare for the heel to touch down first again.

Recap

So, during the gait cycle, the complex design of the foot allows it to change the shape of the arch twice – pronating early in the gait cycle, and supinating later in the gait cycle, based on the function needed from the foot at each time. The bony anatomy and surrounding tissues manage and disperse the forces applied to the foot, protecting us from injury. The widening front of the foot contributes to balance. Many muscles work in a synchronized fashion to offload and protect other structures, support our arch, prevent us from moving in undesired ways (like rolling an ankle or losing our balance), and take advantage of the ability of tendons to store and release energy so the muscles don’t have to work as hard.   

What I hope you noticed about all of this was built in cushioning, arch support, springiness, responsiveness, and rockers – all present (in a healthy foot and ankle) before we put on shoes. My goal with footwear is always to allow the foot to do as many of those original functions exactly as the foot and ankle are designed to, and only compensate for the features that are not present because of illness or injury. So now let’s discuss some of the myths about the role of footwear in foot and ankle health that may be holding some people back from ideal function.

Part 2: Myths

Myth 1: Everyone needs arch support in their shoes to walk properly and prevent pain and injury.

Pronation (the arch lowering) has a bad reputation, but universally saying that all pronation during gait always needs to be corrected just isn’t supported by research. We saw earlier that some pronation is completely normal and beneficial in a healthy foot while walking (and running.) Manipulating the position of the arch is typically only necessary in three types of injuries or medical diagnoses:

• Overload: Arch supporting insoles or shoes can be very beneficial to people with certain injuries or illness that mean their foot or ankle muscles need a rest, or aren’t capable of effectively moving into normal ranges of both pronation and supination. For example, recently I treated someone with a tear in their plantar fascia. We immediately found arch supporting shoe inserts for them to wear for the first 6 weeks, to limit the stress on their foot until it had time to heal. 
• Extremes: Someone who pronates significantly more than average (which usually needs to be determined by a licensed healthcare professional), especially if they’re stuck in pronation (more on that in a moment), may benefit from a shoe that can reduce that some, to promote the forces moving from the foot and up the body in the best available alignment.
• Stuck: One of my highest priorities when it comes to treating an arch is giving the arch access to both pronation and supination. Often in the clinic I see a correlation that someone is more likely to report pain in a foot that can only access one of those positions – the arch either doesn’t lower at all, or stays lowered the whole time during gait. Since both pronation and supination are normal parts of the gait cycle, you can imagine how this would quickly become problematic. For example, a common ankle problem called posterior tibialis tendon dysfunction (PTTD) can cause the arches to fall. When I analyze someone’s gait who has PTTD, often I’ll see their foot still in pronation right before they pick it up to step forward – which is when it should be back in supination. One way to describe this is to say their foot is stuck in pronation.  

Sometimes you can estimate this from a worn out pair of shoes: someone who consistently wears out the outer (pinky toe side) edges of the soles much sooner than the inside aspects might be spending extra time in supination.
To simplify the issue: many people who are stuck in supination need work on the mobility in their foot to be able to relax into pronation, and many people who are stuck in pronation need work on the stability and strength in their foot to be able to return to the more stable supinated position.
If someone’s foot is a bit stuck in supination, which already shifts their weight toward the outside of the foot, and then they put on a shoe that’s intended to really block pronation, in some cases that can exacerbate this tendency and send people even further to the outsides of their feet. And on the flip side, if someone is mildly stuck in pronation and doesn’t have full strength to lift their arch when it’s beneficial, and so we do that for them with a very supportive shoe, that may take away their chance to build up the muscle strength they need for ideal foot function.

So individuals who are really stuck in one of those positions should work with a physical therapist or other rehabilitation professional to improve their specific mobility and stability needs. While they’re working on those skills, they might use arch supports to either support the arch in raising enough until the muscles can do so themselves, or if the arch is stiff and stuck in the high arch position, bring the floor up to that arch. If enough normal mobility and stability can be restored, then many can eventually progress away from needing so much arch support.  

Myth 2: More cushion in a shoe is always better to prevent pain and injury.

As mentioned previously, we already have a built-in cushion on the bottom of our foot! While people with certain injuries or medical diagnoses do need extra protection for their feet, healthy and uninjured people don’t need huge amounts of artificial cushioning separating their feet from the floor. And in fact, people with balance disorders might actually be at higher risk of falling in highly cushioned shoes, since this makes it harder for them to feel the floor beneath their feet, and so then limits the ability of the foot to respond to surface changes (Nigg et al 2021). In the physical therapy clinic, we often instruct our patients to stand on a two inch thick piece of foam as a balance exercise, because it’s so much harder to balance on that than the hard floor. So when I see the current trends in athletic shoes that have almost two inches of foam between the foot and the floor, perhaps you can understand how concerned I become for the wearer’s balance! One test that sounds simple but might surprise you is to try a position or task with your shoes on and shoes off – a good shoe will IMPROVE your balance performance, and a shoe with excessive cushioning may make you worse at that task.

Myth 3: Anyone with a history of any foot injuries should never go barefoot, even in the home.

Certainly, anyone with an active injury or diagnosis affecting their feet should work with their physical therapist or podiatrist to determine what’s appropriate for their footwear. However, people who don’t have any chronic diagnoses like diabetes or rheumatoid arthritis, and no longer have pain or injuries in their feet, may benefit from gradually spending more time barefoot in the home if that’s comfortable for them. Walking around barefoot increases the sensory feedback from the feet, and allows the foot intrinsic muscles to fully function and so gain strength – two factors that are vital to overall foot function!

References:

Nigg BM, Vienneau J, Maurer C, et al. Minimal shoes improve stability and mobility in persons with a history of falls. J Biomech. 2021;116:110219.

Part 3: Shoe Style for Many Healthy People

With all of those mechanics in mind, let’s go over the features of shoes that are often a good choice for many people with healthy feet. Because like everything in physical therapy, the truest answer is a nuanced answer, I’ll provide a caveat for each feature when there are specific medical reasons contradicting the previous point.

• Heel height: High heels change your gait pattern, change how the forces are distributed through the knees, and worsen balance (Chaiwanichsiri et al 2022). A flat shoe will best support foot and ankle function for many people. In the shoe industry this is often referred to as “zero drop” or “minimal heel toe drop” – referring to the difference between the heel height and the height at the very front of the shoe. Athletic shoes that have high amounts of cushion and arch support built in commonly have around 8-12 millimeters of a heel (8-12mm heel toe drop.) When I’m working with someone who wants to optimize their foot and ankle health by changing up footwear, I’ll usually recommend slowly progressing this – such as finding a shoe in the 4-5mm heel toe drop range to wear for several months before progressing to a completely flat shoe. Someone who has worn shoes with high built in heel height for a long time will have calf muscles and tendons that aren’t used to going through their full stretch in every step, so giving them a gradual instead of sharp change will make the process much more comfortable, and less likely to temporarily irritate tissues. 
  • Caveat: people who have tendinopathy or tendinitis in the Achilles or posterior tibialis tendon, or have anterior ankle impingement, often benefit from a heel wedge or a shoe with a built in heel-toe drop to put some slack into the irritated tendon or to allow the ankle to avoid the painful motion of dorsiflexion, at least temporarily.
• Cushion: Many people don’t need much cushion in their shoes, or could progress gradually to less cushion, if they did so at a reasonable rate. Reducing the cushion supports your foot being able to better feel the ground beneath you as the foot is designed to. Moving towards a more minimalist shoe can be beneficial when done correctly. Just walking around for daily life in a minimalist shoe can actually be enough to significantly strengthen the muscles within your feet (Curtis et al 2021). Where this can go wrong is if people do this suddenly, such as switching all their shoes from typical shoes to minimalist, or choosing shoes with minimal cushion or support to wear on a vacation where they walk a great deal more than usual. Reducing how much cushion and support is under your foot is increasing the load on your foot – so just like you wouldn’t walk into a gym having never lifted weights and expect to throw around 300lbs on a barbell, people changing to less supportive shoes have to do so in a gradual and progressive manner over weeks and months. 
  • Caveat: Most diagnoses that are degenerative in nature, such as arthritis, diabetes, and peripheral neuropathy, mean that the feet DO need to be protected with some cushion, because of the changes those diagnoses cause in the tissues of the foot. Anybody with any serious diagnoses including those three above should only take shoe recommendations from a licensed physical therapist, podiatrist, orthotist, or physician who has examined their feet. Also, people with especially high step counts like long distance runners and those who stand or walk extensively, especially on hard surfaces, for work, may benefit from a bit more cushioning in their shoes to prevent discomfort.
• Arch support: Similar to cushion, an ideally functioning foot would not need built in arch support underneath it. As detailed in the gait pattern section – pronation or the arch lowering is a normal part of the gait cycle. So if a foot has no problems or pain, it doesn’t make sense to block it from moving through its normal range of motion. Once again, if someone is used to wearing typical athletic shoes that have high arch support, such as stability or motion control shoes, and they decide to switch to a more minimalist type of shoe, this has to be done slowly and progressively, since this is increasing the load on the foot. 
  • Caveat: Just like you would cast a broken bone, an injured foot might benefit significantly from support for the arch from a shoe insert or built into the shoe. In an otherwise healthy person with an isolated injury, the arch support might be a temporary way to offload the foot during rehabilitation, until normal strength can be restored to the built in arch supporting muscles.
  • Also, again people with diagnoses affecting the feet like diabetes, arthritis, or neuropathy often need an arch support, usually custom made by an orthotist, to protect their arch from the impacts of the diagnosis. 
  • If someone uses an orthotic arch support, it’s usually best to combine this with a neutral shoe because if the insert AND the shoe are both designed to increase the arch height, they may overcorrect the position.
• Closure: Shoes with laces or straps that hold the shoe to the foot are usually best for balance – anything so that you’re not holding the shoe on with your toes. As mentioned during the gait cycle, the front of the foot and the toes are meant to spread out as the foot accepts the weight of the body. So while shoes like flip-flops are a common choice, they may impact the ability of the foot to move through normal ranges of motion, since toes have to squeeze together to hold it on the foot. 
• Flexibility: Much of the time, more flexibility is better. The knuckle where the big toe joins the foot (the first metatarsophalangeal joint), is meant to extend at least 60 degrees right before we pick up our foot. This motion helps stretch the plantar fascia, which helps with the arch raising at the appropriate time, and then when that stretch recoils, helps with the springiness in our step. So similar to arch supports, if a foot has no health concerns, there’s little reason to block it from going through normal ranges of motion – those movements are there for a reason!
  • People with certain diagnoses will need more significant structure to the bottom of the shoe – again diagnoses like diabetes and arthritis. Also, some people with hypermobility (Ehlers Danlos syndrome or otherwise) who have foot pain find some pain relief by giving their joints more stability from a stiffer shoe.
• Toe box: Most people benefit from a wide toe box. Keep in mind – this isn’t to say size wide shoe for everyone – we still want the heel collar (back of the shoe) to hug our heels so we don’t slide around in the shoe. Rather, the shoe needs to be designed such that the front of the shoe is wider than the back of the shoe, and there should be minimal tapering inwards on the big toe side of the front of the foot.
  
  Shoes with a narrow toe box (most modern and popular shoes) squeeze the toes together, preventing normal splay and impacting balance. This may also limit blood flow from one of the arteries going into the foot, and doesn’t allow the front of the foot to spread out the pressure across a larger surface area (Faulks et al 2020, Titchenal et al 2015). To test if a shoe is wide enough at the front, remove the built-in insole and place your bare foot on it. Stand up or actively spread out your toes – if they go significantly over the sides of the insole, you can guess that shoe might be too narrow at the front.
• Toe spring: this refers to the front of the shoe curving upwards.
  
  I often recommend avoiding a high toe spring. Normally our toes rest flat on the floor, which is a big part of how we make normal weight shifts, and keep our balance. So, we’d rather they be able to reach the floor.
  • Caveat: People who have limited range of motion in their big toe, or pain (such as from conditions like arthritis or gout), might actually feel better in a shoe with high toe spring, so that this shape can fake toe extension range of motion and make up for some of their stiffness.

In summary, most of what we know from current research suggests that footwear that leaves the foot to perform most of its normal built in functions as much as possible and feasible, will be the best bet for foot health, balance, and walking function. If someone is experiencing pain, injury, or a serious medical diagnosis, then a qualified professional can help them adjust the right facets of their footwear for their specific diagnosis.

References

Chaiwanichsiri D, Chatchawan U, Sripaiboonkij N. Enhancing footwear safety for fall prevention in older adults: A comprehensive review of design features. Geriatr Orthop Surg Rehabil. 2022;13:21514593221096785

Chiu MC, Wu HC, Chang LY. Effects of shoe sole stiffness on balance and gait in older adults. Gait Posture. 2018;59:86-91.

Curtis R, Willems C, Paoletti P, D’Août K. Daily activity in minimal footwear increases foot strength. Sci Rep. 2021;11:18648. doi:10.1038/s41598-021-98070-0.

Faulks SE, Barnes MJ, Whitwell RL, Knight MM, Bowling FL, Boulton AJ. Passive hallux adduction decreases lateral plantar artery blood flow: A preliminary study of the potential influence of narrow toe box shoes. Gait Posture. 2020;82:20-25. doi:10.1016/j.gaitpost.2020.04.004

Menz HB, Lord SR, Fitzpatrick RC. Acceleration patterns of the head and pelvis when walking on level and irregular surfaces. Gait Posture. 2008;28(4):601-607.

Orabi SA, Hannink E, Abboud RJ, et al. A systematic review of the effect of foot orthoses and shoe characteristics on balance in healthy older adults. Clin Biomech (Bristol, Avon). 2015;30(1):36-47.

Quinlan S, Yan AF, Sinclair P, Hunt A. The evidence for improving balance by strengthening the toe flexor muscles: A systematic review. Gait Posture. 2020;81:56-66. doi:10.1016/j.gaitpost.2020.07.006.

Sherrington C, Fairhall N, Wallbank G, et al. Exercise for preventing falls in older adults: An updated systematic review and meta-analysis. Br J Sports Med. 2017;51(24):1750-1758.

Titchenal MR, Asay JL, Ellis TD, et al. The effect of shoe toe box shape and volume on forefoot interdigital and plantar pressures in healthy females. J Foot Ankle Res. 2015;8:23.

Part 4: Examining Specific Shoes

There’s no one right shoe for everyone. The ideal shoe depends on multiple factors including each individual’s foot structure, mobility, strength, activity level, and health history. In this section we’ll examine a selection of shoes, and how their specifications will influence who is more or less likely to benefit from each specific shoe, with the assumption that user is wearing them to walk, not run. (If you’d like more information about running shoes, the Doctors of Running website has very extensive information from physical therapists on this topic.) 

This section is designed to support your ability to make informed decisions about your own footwear or footwear recommendations for your clients. 

Mission Gait Foundation has no affiliation with any shoe companies. We chose a non-comprehensive sample of shoes that are either very popular or shoes that we have seen work well for multiple clients (which isn’t to say that means the particular shoe is right for whoever may read this!) If you have a medical diagnosis that affects your feet, please choose your footwear in collaboration with your healthcare provider.

Hoka Bondi:

Ssu, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons

Choosing the right shoe can strongly support foot health, performance, and comfort. Understanding the features of various shoes and the impact of those features on the foot and ankle during gait allows us to choose shoes that best support our individual goals, whether that’s reducing pain, improving stability, or transitioning toward more natural foot function. Footwear is just one part of attaining those goals, so if you’re experiencing pain or dysfunction in your feet, contact a local physical therapist to work comprehensively towards your goals.

Part 5: Practical Tips for Transitioning 

Finally, here are some pointers for anyone who is free of injuries or medical problems that impact their feet, and wish to make a change towards a less supportive shoe in order to optimize their foot health.

• Change one level at a time.

For individuals accustomed to traditional athletic footwear with substantial cushioning, arch support, and a significant heel-toe drop, transitional shoes are an excellent first step. This means a shoe with less support and heel height than the wearer is used to, without going directly to minimalist footwear (shoes with no cushion, no arch support, no heel elevation, and a very flexible sole.) Transitioning to minimalist footwear can greatly benefit foot health when done correctly; however, it inevitably increases the load on the foot and must be approached gradually. Transitional footwear is a great way to keep the changes incremental, allowing the tissues in the foot time to adapt. 

• Start with walking and low impact activity in lesser shoes, and barefoot around the home.

If you are not a runner and primarily plan to walk in shoes, evidence strongly supports minimalist footwear. Research indicates that minimalist shoes enhance stability compared to being barefoot or wearing conventional shoes among older adults, younger adults, and individuals with a history of falls (Petersen et al 2020, Cudejko et al 2020). Also, research suggests that simply completing normal daily activities in minimalist footwear can increase your foot muscle strength significantly, but there’s less research about how to structure a transition (Curtis et al 2021). It’s generally advisable to start with shorter durations than one might initially consider necessary – only brief periods of walking in minimalist or transitional shoes. These brief periods can gradually be increased over a period of months until basic walking around for daily life is comfortable in the minimalist or transitional shoes.

• Adjust transition time based on activity intensity.

Conversely, runners and other highly active individuals, such as hikers or those who participate in ruck marching, should anticipate a more extended transition period to lesser shoes. It’s likely wisest to first go through the above described transition until normal life walking tasks like grocery shopping or other errands don’t make your feet tired at all in the new shoes, before introducing them to your sport.

• Runners should be very conservative, and consider only a 5% weekly increase, started after several weeks of non-running activity in minimalist footwear and strengthening. 

This is based on a systematic review published in 2017, which also discussed how the studies vary but have reported high rates of injuries in runners transitioning to minimalist shoes from conventional shoes – especially when they did not follow a transition plan, had less foot muscle size, or had other risk factors (Warne and Gruber 2017). The study also emphasizes the importance of collaborating with a professional to develop an injury-prevention exercise routine that prepares the feet for the increased load associated with the transition.

• Use supportive shoes strategically for high-load events.

Just as runners often benefit from alternating between different pairs of shoes during their training week, non-runners can also adopt a strategic approach. Someone who has successfully transitioned to more minimalist footwear, but still has those more supportive shoes, might benefit from choosing the latter for certain situations. These situations would be anything that represents a significant increase in daily walking compared to normal – for example vacations or special events. Minimizing the risk of injury often involves avoiding sudden, significant increases in load. Going back to that shoe with more built in arch support or cushion that’s likely to offload the foot more can be a way to try to “cancel out” some of the increase in load from the added activity level of the day. 

In summary, transitioning to less supportive footwear can be a valuable step toward optimizing foot health, but it requires patience, careful planning, and a gradual approach. By making incremental changes, listening to your body, and adapting your footwear choices to your activity level and specific needs, you can reduce the risk of injury while building stronger, healthier feet. 

References:

Petersen E, Zech A, Hamacher D. Walking barefoot vs. with minimalist footwear – influence on gait in younger and older adults. BMC Geriatr. 2020;20(1):88. Published 2020 Mar 4. doi:10.1186/s12877-020-1486-3

Cudejko T, Gardiner J, Akpan A, D’Août K. Minimal footwear improves stability and physical function in middle-aged and older people compared to conventional shoes. Clin Biomech (Bristol). 2020;71:139-145. doi:10.1016/j.clinbiomech.2019.11.005

Cudejko T, Gardiner J, Akpan A, D’Août K. Minimal shoes improve stability and mobility in persons with a history of falls. Sci Rep. 2020;10(1):21755. Published 2020 Dec 10. doi:10.1038/s41598-020-78862-6

Curtis R, Willems C, Paoletti P, D’Août K. Daily activity in minimal footwear increases foot strength. Sci Rep. 2021;11:18648. doi:10.1038/s41598-021-98070-0.

Warne JP, Gruber AH. Transitioning to Minimal Footwear: a Systematic Review of Methods and Future Clinical Recommendations. Sports Med Open. 2017;3(1):33. Published 2017 Sep 15. doi:10.1186/s40798-017-0096-x