Softer landings, not new shoes, may protect runners' knees

Knee injuries are among the most common problems runners face, and an entire industry of shoes, insoles, training plans and education programmes claims to prevent them. Very little of that spending has been tested against the simple question of whether it actually reduces injuries. This review set out to gather every randomised trial that aimed to prevent or manage running-related knee injury, to establish which interventions have evidence behind them and which are simply plausible-sounding.

The authors searched MEDLINE, EMBASE, CINAHL, Web of Science and SPORTDiscus up to May 2022 for randomised controlled trials whose primary aim was preventing or managing running-related knee injury. Thirty trials qualified, 18 on prevention and 12 on management, covering novice and recreational running populations. Interventions ranged from running technique retraining and footwear options to multicomponent exercise therapy, graduated running programmes and injury-prevention education delivered online and in person.

The headline result: retraining running technique to land softer reduced the risk of knee injury compared with control treadmill running, with a risk ratio of 0.32, though this came from one trial of 320 participants and was rated low certainty. Across 17 other prevention trials, ranging from 24 to 3287 participants, footwear options, multicomponent exercise therapy, graduated running programmes and education programmes did not influence knee injury risk, with risk ratios spanning 0.55 to 1.06. In runners with patellofemoral pain, technique retraining, medial-wedged foot orthoses, multicomponent exercise therapy and osteopathic manipulation reduced knee pain in the short term.

This is a sobering audit of injury prevention in running: almost everything commonly sold or prescribed for the purpose showed no effect on knee injury risk, while the one bright spot rests on a single low-certainty trial. It complicates the widespread belief that shoe choice is central to injury prevention. The open questions are substantial: whether the soft-landing result replicates in larger and more varied groups, and whether the short-term pain relief options for patellofemoral pain hold up over time.

If you run and worry about your knees, this is a reason to pay more attention to how you land than to what is on your feet, while holding the finding loosely given it rests on one trial. It is also a useful corrective to marketing: nothing in the footwear, programme or education categories moved injury risk in these trials. For existing kneecap pain, several active and passive options showed short-term promise, which is a conversation to have with a professional rather than a plan to self-assemble.