Research on foot/ankle injuries vs footwear choice

[William Puckett]

I'm curious if the many and varied knowledge sources on this forum have articles they can cite with research on injury rates of traditional hiking boots vs lightweight footwear (trail runners or approach shoes).

I'm a convert, BTW, finding that my hiking is happier with lightweight solutions. My Limmer Midweights are languishing in the closet!!

Sooooo…in having discussions with "traditionalists" about the conventional wisdom (safety and injury prevention associated with standard hiking boots), I'd love to be able to respond with citations of research that is on topic.

Anyone?

[Lynn Tramper]

Well, not hiking boots per se, but sudden ankle inversion can happen in any sport, including hiking:

J Athl Train. 2000 Jan;35(1):38-43.

Effects of High-Top and Low-Top Shoes on Ankle Inversion.
Ricard MD, Schulties SS, Saret JJ.

Brigham Young University, Provo, UT.

OBJECTIVE: To determine the differences in the rate and amount of ankle inversion in subjects wearing high-top and low-top shoes. DESIGN AND SETTING: Subjects were filmed at 60 Hz while on an inversion platform that suddenly inverted the right ankle 35 degrees . We measured 5 trials of sudden inversion for each subject in high-top and low-top shoes. SUBJECTS: Twenty male subjects with no history of lower leg injury within the previous 6 months. MEASUREMENTS: We measured ankle inversion using video motion analysis techniques at 60 Hz. A2 x 5 factorial repeated- measures analysis of variance was used to test for significant differences in the amount of inversion, average rate of inversion, and maximum rate of inversion. RESULTS: The high-top shoes significantly reduced the amount and rate of inversion. The high-top shoes reduced the amount of inversion by 4.5 degrees , the maximum rate of inversion by 100.1 degrees /s, and the average rate of inversion by 73.0 degrees /s. CONCLUSIONS: The high-top shoes were more effective in reducing the amount and rate of inversion than the low-top shoes. Depending upon the loading conditions, high-top shoes may help prevent some ankle sprains.

Edit:

I have a pre-existing ankle injury that really benefits from ankle support on uneven terrain (ie high top boots, lateral brace). YMMV. Some people speculate that wearing high top shoes all the time actually makes your ankle ligaments weaker. I haven't seen any research on the topic.

[Ashley Brown]

Some people speculate that wearing high top shoes all the time actually makes your ankle ligaments weaker. I haven't seen any research on the topic.

I hear that all the time and believe it is incorrect.

I used to play high-level volleyball and early in my playing days would sprain an ankle once every year or two. In my mid-twenties I started wearing a flexible ankle brace. Note that I don't have weak ankles, and these sort of braces are nowadays worn by every player in most national teams.

Anyway, since the day I started wearing them I have not turned my ankle once… that's about 10 years worth. I never get on a volleyball court without them on. These braces don't stop my ankle from flexing and I still need strong muscles when landing or pushing off at an angle, but they do make it less likely for the side of my foot to come into contact with the floor and turn under me. A couple of times my ankle has turned under me (eg. after landing on another players foot) but in this scenario the brace absorbs some of the force. I've gotten up and walked away (with a slightly sore, but undamaged ankle) from falls which would have decimated my ankle without a brace.

Although high-top shoes and strong lacing around the top of the shoe is much less supportive than an ankle brace, I believe the general principle is exactly the same. Any form of ankle support will make it less likely to place your foot in a vulnerable position, and will also absorb some of the impact when the ankle does actually turn.

I don't believe the ankle really gets any weaker because even volleyball braces do not significantly reduce the range of "normal" motion of the ankle. So there is still plenty of work for your muscles/ligaments to do and they do not start to wither away simply because you are not pushing them to the limits of what they can handle. It is worth noting also that the permanent damage done by seriously twisting your ankle once is much more significant than any potential "weakening" due to wearing support. Repeated spraining really can make your ankles weak because the ligaments and muscles are torn and may not repair themselves properly.

Having said that, I have pretty strong ankles and don't wear high top boots or shoes. The only time I wear any ankle support at all is playing volleyball. For hiking I'm more than happy just wearing trail runners.

[Mike W]

…

[Tony Beasley]

This is from a posting that I made on the Bushwalk Tasmania forum last November.

After the comment “ that boots do not stop ankle sprains any more that low top shoes do” by a Podiatrist who gave a talk about foot care at my last Canberra Bushwalking Club meeting, I have spent the last week researching the web to see what I could find out.

I typed “boots vs shoes, ankle sprains” into google search engine and came up with many articles and research papers that talked about this issue.

Many of the articles spoke about that boots are better for avoiding sprained ankles, but I felt that this was a personal view as the articles not actually have any hard data to support what they where claiming, A lot of the articles where from boot manufactures and shops. After delving deeper into google and refining my search a bit I found some research papers that have looked into High top shoes (boots) and low top shoes and there effects on ankle sprains. I could not find any research projects into boots vs shoes with respect to bushwalking but there are several studies with basketball players, American foot ball players, soccer players and one comparing army recruits wearing boots and three quarter length basketball style shoes.

I am not sure if these results from studies into ankle injuries from sport and military training can be compared to what happens while bushwalking, my opinion is that it probably does go close.

Here are some conclusions, abstracts and some selected paragraphs from some studies.

Prevention of Acute Ankle Ligament Sprains in Sport

Martin P. Schwellnus

Clinical studies

The factor in footwear design that has most frequently investigated is the possible role of high-top shoes in reducing the risk of ankle sprains (Petrov 1988). The results from three studies indicate that, in the absence of additional taping or external support, wearing high-top shoes does not reduce the risk of ankle sprains. Indeed, in one study, the wearing of low-top shoes resulted in a lower incidence of ankle sprains compared to high-top shoes (Rovere et al. 1988). In two recently published meta-analysises, it was also concluded that the role of footwear in the prevention of ankle sprains was not clear (Quinn et al. 2000).

In summery, although a protective influence of footwear is suggested from the results of biomechanical studies, footwear without additional support from taping and bracing does not appear to have a strong influence on the risk of ankle sprain. The potential negative effect that footwear may have on the proprioceptive function of the foot requires further investigation.

Effect of High-top and low-top shoes on Ankle inversion

Mark D. Ricard, PhD; Shane S. Schuties, PhD, PT, ATC; Jose J. Saret, MS, ATC

Conclusions: The high-top shoes were more effective in reducing the amount and the rate of inversion than low top shoes. Depending on the load conditions, high-top shoes may help prevent some ankle sprains.

This is from the introduction

High-top athletic shoes are frequently to augment ankle support because they may provide increased resistance to inversion. The increase cost of these shoes may be justified if they decrease ankle injury rates. Not all studies, however, support the finding that high-top shoes may reduce the potential for injury. Currently, consensus is lacking among researchers and clinicians concerning the extent to which high-top shoes protect the ankle from inversion trauma.

1: Foot Ankle. 1991 Aug;12(1):26-30.

Risk factors for lateral ankle sprain: a prospective study among military recruits.

Milgrom C, Shlamkovitch N, Finestone A, Eldad A, Laor A, Danon YL, Lavie O, Wosk J, Simkin A.
Department of Orthopaedic Surgery, Hadassah Hospital, Ein Kerem, Jerusalem, Israel.

In a prospective study of risk factors for lateral ankle sprain among 390 male Israeli infantry recruits, a 18% incidence of lateral ankle sprains was found in basic training. There was no statistically significant difference in the incidence of lateral ankle sprains between recruits who trained in modified basketball shoes or standard lightweight infantry boots. By multivariate stepwise logistic regression a statistically significant relationship was found between body weight x height (a magnitude which is proportional to the mass moment of inertia of the body around a horizontal axis through the ankle), a previous history of ankle sprain, and the incidence of lateral ankle sprains. Recruits who were taller and heavier and thus had larger mass moments of inertia (P = 0.004), and those with a prior history of ankle sprain (P = 0.01) had higher lateral ankle sprain morbidity in basic training.

1: Sports Med. 1995 Oct;20(4):277-80.Links

The role of shoes in the prevention of ankle sprains.

Barrett J, Bilisko T.

University of Oklahoma, Health Sciences Center, Oklahoma City, USA.

Ankle sprains are a common sports injury that can cause significant, chronic disability. Studies aimed at prevention through the use of footwear have focused on the biomechanical aspects of foot and ankle anatomy, proprioceptive input of the foot/ankle complex, external stresses applied to the joint, and shoe traction. These studies support the use of high top shoes for ankle sprain prevention because of their ability to limit extreme ranges of motion, provide additional proprioceptive input and decrease external joint stress. Despite this biomechanical evidence, clinical trials are inconclusive as to the clinical benefit of high top shoes in the prevention of ankle sprains. Further study is necessary to delineate the benefits of shoe designs for ankle sprain prevention.

Some other information about ankles

If you have already sprained your ankle you are more likely to sprain your ankle again than someone that had not sprained his or her ankle before.

Athletes who have suffered a previous sprain decreased risk of injury if a brace is worn.

Gender does not appear to be a risk factor for suffering an ankle sprain.

My conclusions

The above abstracts, conclusions and paragraphs is only a little part of what I have read on this topic and on the evidence that I have read my conclusion is that studies have show that it is inconclusive that Boots are better than shoes for lowering the incidence of sprained ankles for sports which bushwalking can be considered part of.

Tony

[Ashley Brown]

I actually wouldn't consider *just* wearing high-tops to give much benefit, because they really provide very little additional support to the ankle.

To get proper support the boots need to be properly laced right up around the top so that the ankle is actually restricted in its movement.

[W I S N E R !]

Personal experience:
Boots or anything remotely stiff on my sole or around my ankle cause a loss of dexterity that probably makes me more prone to injury.

I feel far safer in minimal/lightweight/low top footwear when I can actually feel what's under my feet and they can move, twist, and flex with the terrain.

The only thing I've used boots for in years is wearing crampons for winter climbing.

[William Puckett]

>> In my mid-twenties I started wearing a flexible ankle brace. Note that I don't have weak ankles, and these sort of braces are nowadays worn by every player in most national teams.<<

Ashley, can you be more specific about the ankle brace you wear? Brand name? Generic? Photos?

[CW]

My experience is in line with Craig's. I'm far less likely to turn an ankle enough to injure it with a low top shoe than with a boot or other high top shoe. My gf who has floppy ankles used to turn them at least once on every trip when she was wearing boots. Since switching to a trailrunner she's done it maybe twice.

My opinion:

If you stick a crutch on something and always protect it how can you expect it to get stronger? Anything that causes a lack of mobility is bad I think. The human body wasn't even designed to wear shoes, much less something that locks the ankle.

I tend to use the example of turning an ankle on medium sized rocks (ex. rock garden). A low top shoe is more likely to pull off my foot where a boot is likely to roll and take my ankle with it. I've experience this first hand.

[Lynn Tramper]

Well, my high top boots have a thin and responsive sole and are not very heavy. Just because it's high top doesn't mean it has a full steel shank! My ideal shoe would be high top lace-up with a moccassin sole, except it wouldn't last very long!

Second, as Ashley points out, high tops need to be laced properly to be effective.

Third, I also never *needed* the support of high tops before I injured three ligaments in one ankle. In fact I used to sprint competitively…in bare feet, and often hiked sections of trail without shoes on. So as also pointed out, previous ankle injury can really change the footware needs I now wear an ankle brace with low tops, that limits lateral motion while allowing full dorsoflexion. I find it more comfrotable to walk in high top boots than to walk in low tops with one foot in a stiff brace. I think we've evolved to walk barefoot perfectly well, but injuries have always been a part of the human condition that changes such things.

Fourth as to the research, although it is conflicting, high top shoes do appear to protect against excessive inversion due to *unexpected* and sudden rolling of the foot. It is the enexpected and sudden nature that is the dangerous part of walking. Without high top boots, I now roll my (bad) ankle even walking on flat sections of track due to lack of lateral satbility :(

[Zack Karas]

While I don't know what type of ankle brace Ashley uses, I have had 6 ankle sprains to my right ankle and now use the ASO ankle brace. My last two sprains came while backpacking, and believe me–it isn't fun hiking out for several days on a sprained ankle. I've now hiked well over 5000 miles since starting to wear the brace and I've had zero ankle rolling/problems with it, can still use it with my trail runners, I find it comfortable, and possibly most importantly it gives me the confidence to hike without babying my ankle (and creating compensation injuries unintentionally). The brace weighs 4 ounces and is far more stable than any traditional hiking boot. I would probably go so far as to recommend them to someone who is afraid of using just trail runners as they are the safer and lighter alternative.

[Jeffrey Davis]

Since incurring a major ankle sprain while trail running in January, I've been wearing an ASO brace underneath Inov8 370s. The brace weighs about 4 ounces and the Inov8s are 14 ounces each. I've found the combination light high tops with the ankle brace very effective and have had no further issues while doing many miles on varying terrain. Highly recommend the combination.

[Ashley Brown]

Ashley, can you be more specific about the ankle brace you wear? Brand name? Generic? Photos?

I use active ankles. As I mentioned, they are used by many university, state and national volleyball teams.

You can see pics on the website above. The brace is placed into the shoe before you put your shoe/brace on. In fact, I leave my braces attached to my shoes permanently (though you can just pull them out, it only takes a second).

The flat bottom of the brace is placed *under* the insole inside your shoe. That way you don't actually feel like you are stepping on anything (the base is very thin and completely flat). Next you step into your shoe as normal and do up your laces. Finally you wrap the velcro straps around your lower leg just above your ankle bone.

Active ankles give you full forwards-backwards motion of the ankle, and allow a decent amount of lateral movement too due to the flexiness of the plastic. The more they are bent laterally though the more they resist.

If anyone is thinking of giving them a try, just note you really need to wear a sock which rises above the ankle bone. A sock underneath the strap just makes it much more comfortable.

I'm not sure whether anyone uses these for hiking. They are probably stronger than you need. If I had ankle problems I would probably just learn to strap my ankle up properly with sports tape. Still it works great for volleyball. I will not step on to a court without a pair on!

EDIT: Gee, animated images are annoying aren't they!!!

[Ashley Brown]

Those ASO braces look like they would do the job too. Maybe more comfortable than active ankles? Probably just a personal preference thing depending on fit etc.

[Nick Gatel]

I think that instead of focusing on footwear, we should look at the hiker.

– How heavy is the pack?

– How agile is the hiker?

– What kind of physical condition is the hiker in?

– What are the trail conditions?

– How tired is the hiker?

– Is the hiker in need of food or water?

– How alert/focused is the hiker?

etc.

I bet the above have more impact on injuries, than boots or shoes.

I have only had one serious injury in over 40 years of hiking. Last December I twisted my knee while hiking up a steep hill going cross country. The injury was due to the fact that I was looking at the top of the ridge, instead of looking at where I was hiking, and I slipped and slid down the hill. My right foot slipped and the left foot stayed planted. I could have blamed in on my boots for not providing secure footing… but I was just not paying attention.

However, I have found that the lighter the footwear, the quicker my brain reacts to footing conditions. If I am wearing racing flats (< 7 oz) or FiveFingers, I never stumble or trip, but the heavier the footwear the more often I do.

[Brad Groves]

I've had several major ankle sprains and am disinclined to invite further injury. As such, I hike in boots. Although I have suffered all of my sprains in low top shoes or low boots, I have not had any problems at all since I started wearing boots. I used to play soccer; I always had my ankles taped, but still managed damage. I've also induced injury with low-top/mid boots while backpacking.

Stiffer, higher boots provide a level platform on which to stand. I do not expect my ankles to get stronger; they have had too much permanent damage. Therefore, and to prevent further injury, I wear supportive footwear. I do not find that boots restrict my motions or activity in any way. In fact, I find the greater support and stability offered by boots allows me much more range in "attacking" the trail. In other words, I can hop rocks and all the things people talk about using trail runners for… except I don't turn my ankles. If you have a solid platform and lateral support you will not roll and "take your ankle with it," it will keep your ankle in line with your foot. I've had very much experience with this first hand ;P ! And Chris, I have to say: if you're counting on your shoes falling off when you get on uneven footing, the shoes either don't fit or aren't laced properly.

In short, I know this is anecdotal and not research as requested by the OP. However, I think it's important in the sea of trail-runner fiends to voice support (sorry, pun intended) for boots. I haven't injured my ankles since I started wearing them; I scramble and hop and have great agility in the woods with them; they reduce my foot fatigue compared to what it used to be with shoes…

Cheers-

[Jeffrey Davis]

Nick – you make astute comments as always, but in my case my ankle injury had nothing to do with pack weight, fitness, or anything else relative to hiking. I was crosstraining for a 14er summit by trail running. I didn't even have a pack on or any other gear besides shorts and a t-shirt. However, busting an ankle can clearly put a crimp in hiking plans, thus the need for the ankle support now while my foot fully heals. I imagine that happens as other active hikers engage in non-hiking sports like skiing or whatnot and then have to compensate/account for the ankle while hiking. Cheers.

[Nick Gatel]

Jeff,

Agreed. When I was in high school, I was prone to sprained ankles as a basketball player. I had to tape them and was the only guy on the team to wear high-tops (in those days the Converse sneakers where the premium shoe).

We need to call these injuries accidents. So are shoe type or something else the primary cause. I vote for something else.

Of course if anyone has a previous injury, then it makes sense that they use alternative equipment during rehabilitation, or if an injury will never heal properly, then the "standard" equipment is not applicable.

I attribute my general lack of hiking injuries to physical conditioning and a genetic metabolism that allows me to stay fairly agile and light as I approach my 6th decade. But my injury last year was due to a lack of attention. It happens to all of us, and thus we have accidents.

[William Puckett]

Nick,

Your posts on this topic caused me to think back to my own "twisted ankle" episodes while hiking. While none has yet been serious enough to qualify as a sprain (well, maybe a Type 1…but not Type 2 or Type 3), in each case I was looking around and not paying attention to the trail and foot placement.

So, since looking around and inattention is part of the real world, I recognize that I have significant responsibility for my ankle health. With heavy loads (e.g. canoe portaging or Duluth pack size loads), I watch every foot placement. If I want to look around with a big load, I do so where the trail is clear and somewhat even…or even better just stop for a moment.

Here's what my own experience suggests…
1. Lightweight loads reduce the risk of a serious ankle injury while heavier loads increase the risk.
2. Lightweight shoes designed for trail usage (e.g. trail runners or approach shoes) are no more prone to ankle injury than traditional hiking boots.
3. A good heel counter and heel "flare" are important trail shoe design features that help me keep my center of gravity inboard of my shoes.
4. Looking at several designs for flexible ankle braces (for instance the two described earlier in this thread), I see reasonable solutions that appear lighter and more reasonable than a 3+ lb boot fully laced.

As is often the case, individual situations and usage may dictate that YMMV.

[Lynn Tramper]

"1. Lightweight loads reduce the risk of a serious ankle injury while heavier loads increase the risk."

Absolutely. This is possibly the biggest factor in *new* injuries. "Load" weight also includes bodyweight…

"2. Lightweight shoes designed for trail usage (e.g. trail runners or approach shoes) are no more prone to ankle injury than traditional hiking boots."

This is still in dispute as far as proper research is concerned. The evidence is anecdotal at best.

"4. Looking at several designs for flexible ankle braces (for instance the two described earlier in this thread), I see reasonable solutions that appear lighter and more reasonable than a 3+ lb boot fully laced."

There are good boots out ther lighter than 3+ lbs, and I have yet to find an ankle brace that is comfortable enough to hike in all day. My selection of comfortable boots are all in the 1kg (2.2 lb) range.

5. The *athlete's* bodyweight is a major factor in ankle injuries. Whether that is due to a heavy pack, or excess bodyweight (or both), is probably irrelevant.

And like others, my injury was an *accident* not related to footware (horse-riding injury), which now leaves me vulnerable to ankle injuries.

[Brad Groves]

I would add, anecdotally, that I don't think physical fitness has much bearing on propensity for ankle injury in our given context. Yes, I can understand why someone would make that argument. However, all of my injuries were at peak fitness… running 10Ks, cycling 60Ks, extensive weight training, and so forth. Another side note: I walk much like I ski, "picking a line" down the trail for good foot placements, very cognizant of such… but accidents do happen…

[William Puckett]

Brad,

Here's an abstract I found…which seems to agree that physical fitness (or lack thereof) is not a predictor of ankle injuries.

"Abstract
Objective: To review the prospective studies of ankle-ligament-injury risk factors.
Data Sources: We searched MEDLINE from 1978 to 2001 using the terms ankle, ligament, injury, risk factor, and epidemiology.
Data Synthesis: The results included many studies on the treatment and prevention of ankle injuries. There were, however, very few prospective studies focusing on identifying the risk factors that predispose an athlete to ankle-ligament trauma.
Conclusions/Recommendations: There is some agreement among authors with regard to the risk factors for ankle-ligament injury; however, considerable controversy remains. Although female athletes are at significantly greater risk of suffering a serious knee sprain, such as disruption of the anterior cruciate ligament, this does not appear to be the case for ankle-ligament sprains. Therefore, sex does not appear to be a risk factor for suffering an ankle-ligament sprain. Athletes who have suffered a previous sprain have a decreased risk of reinjury if a brace is worn, and the consensus is that generalized joint laxity and anatomical foot type are not risk factors for ankle sprains. However, the literature is divided with regard to whether or not height, weight, limb dominance, ankle-joint laxity, anatomical alignment, muscle strength, muscle-reaction time, and postural sway are risk factors for ankle sprains. Future research is needed on this topic to develop a consensus on all ankle-injury risk factors. This will allow future intervention studies to be designed that will reduce the incidence and severity of this common injury."

The authors go on to say "Most professionals involved in the care of athletes would agree that prevention of injury is important. However, when one considers the most common injury experienced in sport, ankle-ligament sprains, a dilemma arises because there is very little consensus in the literature with regard to the risk factors for ankle injury derived from well-controlled, prospective investigations. Our review of the available prospective studies found some consensus: (1) sex does not appear to be a risk factor for suffering an ankle sprain, (2) the use of a brace is effective for reducing the risk of reinjuring the ankle, and (3) foot type (classified as supinated, neutral, or pronated) and generalized joint laxity are not ankle-injury risk factors. At this point, there is little consensus in the literature with regard to whether or not height, weight, limb dominance, ankle-joint laxity, anatomical alignment, muscle strength, muscle-reaction time, and postural sway are risk factors for ankle sprains."

So…your sex is not a risk factor, nor foot type. As for the rest (strength, posture, etc.) the evidence is inconclusive.

[Lynn Tramper]

William, that is a very nice summary. I would go so far as to say that ankle injuries are as much a matter of *bad luck* as much anything else. I would also say that the ankle seems an inherently complicated joint, and prone to traumatic injury, as opposed to wear and tear injuries like knees and hips often suffer. Heck, you can replace a knee or hip these days, but ankle replacements are still a long way from being user-friendly :( I guess the *good news* is that a fused ankle is still serviceavble, and pretty much resistant to further ligament damage. I am awaiting one of these fusions with some dread and some relief!

As an aside for why you might go out of your way to prevent an initial ankle ligament injury, there appears a direct and linear relationship between the number of ankle ligaments you damage and the risk/time to osteoarthritis. One severe ligament injury equals ~25 years until OA, two ligaments equals ~ 20 years until OA, and three ligaments equals ~ 15 years until OA. I drew the short straw with three ligaments in one go. I made it to 17 years post injury before the OA was diagnosed.

[MIchael MacCormac]

physical fitness is hard to factor out- of course athletes in peak training suffer alot of injuries- there risk exposure is much hgher. Fitness probably reduces the RATE of injury– however you have greater exposure by training.

[Nick Gatel]

>> physical fitness is hard to factor out- of course athletes in peak training suffer alot of injuries- there risk exposure is much hgher. Fitness probably reduces the RATE of injury– however you have greater exposure by training.

Agree.

Most of us are not athletes. We are recreational hikers.

[Author]

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