Orthopedic Foot Surgeon Weighs In on HOKAs and Other Ultra-Cushioned Shoes
Ultra-cushioned running and walking shoes, such as HOKAs, have become popular among athletes, active adults and people who spend long hours on their feet. While their thick foam midsoles can improve comfort, absorb impact and reduce repetitive loading, they may also affect stability in certain situations.
We spoke with HOI orthopedic foot and ankle surgeon Brandon Haghverdian, MD, who explained the benefits and potential drawbacks of footwear with thick cushioning, who may benefit most and how to reduce the risk of injury when wearing these shoes.
Q: What separates the cushioning of HOKAs from other standard running/tennis shoes? What is the thick cushioning meant to do?
A: Ultra-cushioned or maximalist shoes such as HOKAs have a thicker foam midsole, which are designed to absorb impact and reduce the amount of force transmitted through the feet and lower extremities with each step. The goal is to improve comfort, decrease repetitive loading on joints and soft tissues and reduce fatigue during prolonged walking or running.
Q: How might HOKAs and similar shoes raise the risk of ankle, leg and foot injuries?
A: For most people, these shoes are safe and may actually reduce impact-related injuries. That said, the higher sole height places the foot farther from the ground, which can reduce feedback and slightly reduce stability at the ankle. On uneven terrain or during rapid cutting and pivoting sports, this may increase the risk of an ankle sprain in susceptible individuals with baseline laxity or looseness of the ankle.
Q: What is the effect of increased cushioning on certain tendons, such as the Achilles, and muscles? How can prolonged use cause damage to these areas?
A: The increased cushioning can reduce repetitive impact on muscles and tendons, which many runners find beneficial. However, because many maximalist shoes also have a slight lift on the heel, they may decrease strain on the Achilles tendon while shifting loads elsewhere. Most injuries are related to training errors or abrupt footwear changes rather than the shoe itself.
Q: Can wearing HOKAs and similar shoes for long periods of time cause pain or issues that move up the legs and to the back?
A: Footwear certainly influences the mechanics of the entire kinetic chain, but there's no good evidence that ultra-cushioned shoes inherently cause knee, hip or back pain. In some individuals they may actually reduce symptoms by decreasing impact forces, while others may simply do better in a different shoe depending on their gait, foot structure, and underlying conditions.
Q: Is there a risk of more serious or longer-term issues like a stress fracture or plantar fasciitis?
A: Current evidence does not show that maximal cushioning increases the risk of stress fractures or plantar fasciitis. In fact, many patients with plantar heel pain find cushioned footwear more comfortable because it decreases repetitive loading. The most important risk factors remain training volume, biomechanics, bone health and how quickly activity levels increase.
Q: Are certain groups of people more prone to injuries from HOKAs and similar shoes, such as older people, people with previous injuries, people with arthritis or other surgeries?
A: Many groups actually benefit from additional cushioning because of improved comfort and reduced repetitive impact during long periods of standing or walking. However, no single shoe works for everyone. Individuals with chronic ankle instability or those who frequently walk on uneven ground may prefer a shoe with a lower shoe height for greater stability.
Q: Are there things people can do to lower their risk of injuries while wearing ultra-cushioned shoes?
A: The most important principle is to match the shoe to the activity and transition gradually if you're changing footwear styles. Runners should avoid making sudden mileage increases when switching shoes. Anyone who notices persistent discomfort should consider being evaluated to determine whether a different shoe is a better fit for their biomechanics.
About the Author:
Brandon Haghverdian, MD is an orthopedic surgeon who specializes in foot and ankle surgery, affiliated with Hoag Orthopedic Institute. Read more here.
