Does a cushier shoe reduce knee pain in Runners?

It’s a common story for us to hear. When knee pain starts to occur, runners first turn to their shoes as the source of their problems. In some of these circumstances, the natural inclination is to think that the issue lies with the shoe’s cushioning. It makes sense, if you experience knee pain as your foot strikes, then adding more cushioning should help, right?

The answer, counter-intuitively, is no! In this article, we are going to explain the relationship between your shoes and how it may affect your knees.

The most common issue in runners is patellofemoral pain, affecting 16% of all runners(1). Patellofemoral pain (unsurprisingly commonly referred to as runner’s knee), is rather broadly defined as pain at or around the patella (AKA knee cap) during activities that load this joint, such as running, squatting, or going downstairs.

While there are a lot of different approaches we can take to treating patellofemoral pain, they all boil down to the following:

1.     Manual therapy for short-term pain relief

2.     Build the joint and the surrounding structures to be stronger and more resilient

3.     Reduce the relative force exerted on the knee during aggravating activities.

For the sake of this article, we are going to focus on the third component.

How to reduce the Impact on the knee in running

There are a number of ways we can reduce the force felt in the knee during training. Your physiotherapist or chiropractor may adjust several components, including the following:

1.     Your training volume

This component always freaks out patients. Don’t worry! Changing your training program would be temporary, and it doesn’t mean we cut it down altogether, but maybe just scale it back a bit. We want to keep you moving as much as your body will tolerate, and where we can see you are recuperating. Many of our therapists are also runners, so we get it. Rest assured, we will create a program with you to build it back up.

2.     Change the terrain

If impact is the issue, we can change the surface you run on to modify how much force is being put through your legs. We’re not just talking about road versus trail here; we may also want to adjust the amount of elevation you are doing as well.

3.     Change your footwear

Unsurprisingly to the astute reader, we can also change the shoes we run in. Adjusting the shoes can make a huge difference in the mechanics of how a person runs and where the force of each step is absorbed by the body. While there are a number of ways to organize running shoes, the simplest and most commonly asked about comparison is minimalist vs rocker sole and/or maximalist shoes. Here, we have two competing schools of thought: 1) we should reduce impact on our feet in running, given the high impact of roads, and 2) we should structure our shoes to match how we have evolved to run for millennia.

And so we arrive back to our topic of discussion. Do cushier AKA maximalist shoes reduce impact on our knees?

The Research

A systematic review published a couple of years ago did a deep dive into all the past evidence on this topic (2). The following are their results:

Runners in minimalist footwear experience an average of 9.5% less load through their knees compared to conventional footwear.

Runners in rocker soled shoes had an increase in patellofemoral joint load of 12%!

This implies that if we take a runner and we swap out their rocker-sole hokas for a pair of minimalist shoes, we would see a decreased load through the knee joints of over 20%!

Now, this seems counterintuitive. Shouldn’t more cushioning reduce joint impact? If we were jumping straight up and down, yes. However, there are a few explanations for the reduced impact when running in minimalist shoes:

1.     Runners in minimalist shoes tend to adopt a more midfoot strike, which has less patellofemoral impact compared to rearfoot strikers (3)

2.     Runners in minimalist shoes lead to less ground contact time and therefore less time loading the patellofemoral joint (4)

One last layer of complexity. While there is good evidence to show that minimalist shoes reduce patellofemoral impact, the jury is out on whether that actually leads to less knee pain. In truth, patellofemoral impact is just one of many elements that play into whether a person experiences pain in running. Our approach at Pursuit Physiotherapy is to consider your footwear as a part of the picture, but it is just one of many interventions we will do to address that pesky runner’s knee.

References:

1.  Kakouris N, Yener N, Fong DTP. A systematic review of running-related musculoskeletal injuries in runners. J Sport Health Sci. 2021;10(5):513-522. doi:10.1016/j.jshs.2021.04.001

2.  Kayll SA, Hinman RS, Bryant AL, Bennell KL, Rowe PL, Paterson KL. Do biomechanical foot-based interventions reduce patellofemoral joint loads in adults with and without patellofemoral pain or osteoarthritis? A systematic review and meta-analysis. Br J Sports Med. 2023;57(13):872-881. doi:10.1136/bjsports-2022-106542

3.  Hamill J, Gruber AH. Is changing footstrike pattern beneficial to runners?. J Sport Health Sci. 2017;6(2):146-153. doi:10.1016/j.jshs.2017.02.004

4.  Gillinov SM, Laux S, Kuivila T, Hass D, Joy SM. Effect of Minimalist Footwear on Running Efficiency: A Randomized Crossover Trial. Sports Health. 2015;7(3):256-260. doi:10.1177/1941738115571093