Running injury paradigms and their influence on footwear design features and runner assessment methods: a focused review to advance evidence-based practice for running medicine clinicians

Key points

1. 01Four major paradigms have driven running shoe design: Pronation Control, Impact Force Modification, Habitual Joint (Motion) Path, and Comfort Filter.
2. 02Evidence for the Pronation Control paradigm is not strongly supported: motion control shoes reduce rearfoot motion but assigning shoes by arch type does not significantly reduce injury rates.
3. 03Cushioning does not consistently reduce external vertical ground reaction forces, and only two studies have examined cushioning and injury risk with mixed results.
4. 04The newer Habitual Joint Path and Comfort Filter paradigms are more individualized but remain largely untested in prospective injury studies.
5. 05The best evidence-based general recommendation is a shoe that is lightweight, comfortable, and has as little pronation control technology as possible.

How it was conducted

Design

Focused narrative review

Topic

Running injury paradigms, footwear construction features, and runner assessment methods for clinicians

Scope

Four major injury paradigms that have driven footwear design over the last half-century

Target audience

Running medicine clinicians and sports medicine practitioners

Evidence types reviewed

RCTs, prospective cohort studies, biomechanical laboratory studies, and expert commentary

What they found

• Pronation control: assigning shoes by arch type (motion control, stability, neutral) did not significantly reduce injury rates during weeks of basic training in two large military studies (Knapik et al.).
• Pronation control: female recreational runners randomly assigned motion control shoes missed a mean of 3.03 days due to pain vs. 1.06 days in the neutral group and 0.49 days in the stability group (Ryan et al.).
• Impact Force Modification: no sufficient evidence that increasing cushioning via midsole material reduces external vertical ground reaction forces (Baltich et al.; Addison and Lieberman; Malisoux et al.).
• Minimalist shoes in rearfoot strikers tend to produce higher peak ground reaction forces and vertical loading rates compared to conventional shoes (Paquette et al.; Willson et al.; Willy and Davis; Rice et al.).
• Maximalist shoes: midsole thickness increase did not reduce vertical ground reaction force (Agresta et al.; Kulma et al.) or joint resultant forces (Sinclair et al.; Chan et al.) but appeared less likely to cause running-related pain or time-loss compared to minimalist shoes (Agresta et al.).
• Comfort Filter: military personnel using their most comfortable insole had 53% fewer lower-extremity injuries than controls (Mundermann et al.); only 2 studies have directly tested biomechanical variability as a function of comfort with inconclusive results.
• Habitual Joint Path: one study found medial femur, medial tibia, and patella cartilage volume reductions were larger after 60 min of running in a shoe that increased a runner's deviation from their habitual joint path compared to one that reduced the deviation (Willwacher et al.).
• Shoe mass: every 100 g added increases oxygen consumption by approximately 1%; increasing shoe mass has been found to increase running time per distance and energy consumption.

Limitations

• This is a narrative review, not a systematic review or meta-analysis, so study selection may reflect author judgment rather than exhaustive search.
• The review explicitly excludes gait retraining and strength training, which are important and inter-related strategies for injury risk reduction.
• No standardized thresholds exist for classifying excessive pronation, high loading rates, or habitual path deviation, making clinical translation difficult.
• Most reviewed studies were conducted in laboratory settings with healthy runners, limiting generalizability to injured or highly diverse clinical populations.

Why it matters

For patients

Runners seeking shoe advice should know that no shoe type has been proven to prevent injuries, and the best general guidance is to choose the lightest, most comfortable shoe with minimal built-in arch control.

For clinicians

Clinicians should understand the four paradigms underlying footwear design, use them as a framework for individualizing shoe recommendations, and move away from arch-type-based prescriptions given the lack of supporting evidence.

For readers

This review provides a clinician-facing synthesis of running shoe science, making technical footwear research accessible and placing current paradigms in historical and evidentiary context.