Physiotherapists are in a perfect position to be prescribing running shoes for our patients.
We have insights into their injuries, their biomechanics and their risk factors.
But prescribing running shoes has come a long way in the last 15 years.
We’ve moved away from the marketing team’s paradigm of cushioning vs support (“OMG, you pronate!!! Quick, bring me a support shoe…”)
Around 2005-2010, we transitioned towards, and very quickly away from, a barefoot running phase.
Now we’re going with a more common sense approach to prescribing running shoes, acknowledging that everyone is different and personal preference plays a big part.
So here’s our simple, common sense guide for Physios prescribing running shoes for their patients.
Basic features for prescribing running shoes
Firstly you need to understand the different parameters of a shoe that you can manipulate to suit your patient’s needs.
Heel-toe offset
Heel toe offset or heel toe drop (aka. just the “drop” of a shoe) is the difference in height between the rearfoot and forefoot sections of the shoe.
It’s measured in millimetres, with a flat shoe being 0mm and the upper range of high drops around 12-13mm.
Most shoes sit in the 5-10mm range.
Last
This refers to the shape of the shoe, generally grouped into “straight”, “universal” and “curved”.
Most brands stick to a consistent shape – that’s why you’ll often hear people saying that “Asics always seems to work for me” or “I feel most comfortable in Saucony shoes“.
That’s not just brand loyalty, it’s usually a match for their foot shape.
You can also observe the foot and judge its shape by looking at the plantar surface.
Width and volume
There’s a few variations on shoe width and you’ll need to understand the differences.
Firstly, some brands are wider makes than others.
They’re all labelled as a standard fit (B width for female shoes and D with for male shoes) but their actual dimensions differ.
Secondly, some shoes have a wide/extra wide fit option (D/2E in females and 2E/4E in males).
These are shoes within their range that have been made with extra width across the forefoot.
Lastly, we have volume – don’t get this mixed up with width.
Volume refers to how much space you have overall, most notably across the dorsal surface of the midfoot.
Low volume shoes (like many football boots) are a squeeze to get into, while high volume shoes are for chunky, fat feet (although don’t say that in front of a patient…)
Stack height
This is literally the height of the shoe.
Stack height refers to how thick the midsole is and how much material is between the foot and the ground.
Lower stack heights (under 20mm) means you’ll feel almost everything.
Higher stack heights (above 32mm) means you’ll feel next to nothing.
We’ll cover the pros and cons of each later in the post.
Support level
The last feature to mention is the level of support.
This is a very polarising topic and we need to separate the marketing info from the research info (aka. reality).
Think of “support” as rigidity of the midsole – more support just means a firmer base for the foot to land on.
“Neutral” shoes are just a less firm base – good for softness, harder to stabilise on.
Worth a mention, although becoming far less popular, is “motion control”.
Think of it as the most rigid shoe with very little flexibility in the midsole.
Rarely needed, it’s saved for the worst foot biomechanics that can’t be helped by our normal approaches (exercise, orthotics, etc).
Step-by-step method for prescribing running shoes
For this, you’ll need a patient in front of you (Facebook messages about “what shoes do you recommended?” are a waste of time).
You’ll also need to know their injury history, although we’re assuming you’ve assessed them before this point.
Lastly, it’d be helpful to have their previous running shoes with at least 100km of running in them.
Injury history
A patient’s injury history tells you what they’re vulnerable to but doesn’t tell you why.
A recurrent calf injury might be a good justification to offload the calves, but only if there is a biomechanical reason why calves are overloading (lack of dorsiflexion, etc).
If calves are overloading to compensate for another issue, reducing calf loading will only make the underlying issue worse.
If you’re prescribing running shoes for their current injury, decide if you want to reduce loading on the injured area or redistribute loading elsewhere (same effect, different underlying reasoning).
Evaluate current footwear
Looking at their existing running shoes can be one of the most helpful inputs when prescribing running shoes.
Unlike watching them perform 10 single leg squats, the shoe shows how they’re loading during their runs and with fatigue.
First place the shoes on a flat surface and look at the heel cups (rigid part of the upper that wraps around the heel) – are they tilted or bending medially?
Second, observe the midsole, particularly on the medial side of the rear and midfoot.
Look for significant horizontal creasing, signs that focal compression of the material as the foot pronates excessively.
Next, assess the upper around the medial midfoot and both sides of the forefoot.
Look for stretching of the fabric – stretching over the medial midfoot may mean that they’re rolling over the top of the midsole during pronation.
Stretching around EITHER 1st or 5th toe might indicate that the shape of the shoe isn’t right for them (eg. the shoe is curved while the foot is straight, leading to pressure against the 5th toe).
Stretching around BOTH the 1st and 5th might indicate that the shoe isn’t wide enough for their foot.
Assessing and modifying different parameters
For the dynamic assessment part of prescribing running shoes, you’ll have the patient performing a reproducible, symptomatic movement without shoes on.
For the examples below, we’ll use a single leg squat.
Get them to perform a few single leg squats and describe their pain (ie. pain scale, quality, at what depth, etc).
If you feel that dorsiflexion is part of the trouble, add a heel raise (use a small block or weight plate, raising them around 20mm) and reassess their pain.
Then we can test the effect of pronation support with some Low Dye taping.
Apply the tape and reassess the movement without the heel raise in place.
If both seemed to help, you can then add the heel raise with the Low Dye tape and see if the combination works even better.
If Low Dye taping helped a bit, think of recommending a more structured shoe (aka supportive).
If Low Dye taping helped a lot, think of recommending a soft orthotic for additional pronation support.
Ground feel
This is probably the trickiest to decipher if you’re prescribing running shoes from a clinical setting.
Feeling the ground provides more feedback to the brain to control movement, assisting with motor control issues.
But more cushioning allows for less knee flexion and less patellofemoral loading on landing.
A very basic test for this is to try barefoot hopping and assess pain and control.
Then repeat the test with shoes on. If the extra protection reduces patellofemoral pain, more cushioning is a good idea.
If shoes on reduces control, then a lower stack height should be helpful.
Shortcut to knowledge
Once you’ve done all that testing, you’ll have a rough idea of the parameters that need to be adjusted when prescribing running shoes for your patient.
Then you can rely on your encyclopaedic knowledge of every shoe on the market…..nah, just kidding!
Then you head for a website with all the parameters listed and find your match.
I use Running Warehouse’s Shoe Filter (on the “Running Shoes” page at the top of the left sidebar) when prescribing running shoes.
Punch in your patient’s brand preference, the width required, neutral or support, the heel toe offset and stack height.
It then gives you a list of all the options that fit the parameters.
Summary
This approach to prescribing running shoes helps you determine which parameters to adjust for new shoes.
Shape = brand preference and observed shape of foot.
Width = stretching of existing shoe upper and obsevation.
Support level = Low Dye taping test.
Heel toe offset = heel raise test with small block.
Stack height = personal preference and hopping test.
It’s not a bulletproof system as there is a lot of personal preference in shoes, and not just the colour.
Despite using a sound biomechanical rationale for prescribing running shoes, some people just prefer a particular feel.
Which is why I recommend trying all shoes on before buying something different to their previous model.
This framework can point them in the right direction but always remember that prescribing running shoes is an exact science.
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