Minimal shoes improve stability and mobility in persons with a history of falls

Falls affect 30–60% of older adults annually, with 10–20% resulting in injury, hospitalization, or death, and substantial healthcare costs. Postural and walking instabilities and reduced plantar sensation are key risk factors for falls in older age. Footwear can alter gait and impair stability by diminishing perception of walking surfaces. Modern conventional footwear often includes cushioning, arch supports, restrictive toe boxes, and raised heels, which may reduce sensory input compared with barefoot conditions. Minimal shoes that better reproduce barefoot neuro-mechanics may enhance stability and mobility. Prior work from the authors showed minimal shoes improved stability and mobility compared with conventional shoes in middle-aged and older adults, with wider and harder soles offering greater benefits. Research directly comparing conventional shoes, minimal shoes, and barefoot in people with a history of falls, and testing effects under degraded visual input or cognitive load, is lacking. This study aimed to compare footwear effects on stability and mobility in persons with a history of falls and to assess whether visual deprivation or dual-tasking modifies footwear effects. The authors hypothesized minimal shoes would confer greater stability than conventional shoes.

Existing literature identifies postural and gait instability as major fall risk factors in older adults and emphasizes the role of plantar cutaneous sensation in maintaining stability. Systematic reviews indicate footwear can influence fall risk, but evidence is limited and heterogeneous. Features of conventional footwear such as heel elevation and cushioning may impair somatosensory feedback and control of gait. Previous work by the current authors found minimal shoes comparable to barefoot and superior to conventional shoes for postural and walking stability, with wider/harder soles further improving outcomes. Other studies have reported mixed findings; for example, Broscheid and Zech observed worse postural control in barefoot/minimal conditions compared to conventional shoes, potentially due to methodological differences (clinical error scoring vs. instrumented CoP measures). Additional literature suggests higher heel height may increase lateral instability via higher tipping angles, and that wider soles can enlarge the base of support and enhance plantar mechanoreceptor stimulation. Overall, the literature suggests potential benefits of minimalist features but underscores the need for rigorous comparative studies in populations at risk of falls.

Design: Cross-sectional observational study with within-participant repeated measures. Footwear conditions were tested in randomized order (www.randomizer.org): (1) conventional shoes, (2) minimal shoes, (3) barefoot. Ethics approval: 19/EM/0197; protocol preregistered (NCT03874728). Participants: Community-dwelling adults aged ≥60 years with ≥1 self-reported fall after age 60. Exclusions: macrovascular disease (angina, stroke, peripheral vascular disease, diabetes), neuromuscular disease (multiple sclerosis, Alzheimer’s, Parkinson’s), use of walking aid, recent lower-limb surgery ≤3 months, or pain ≥8/10. Recruitment: Nov 2019–Mar 2020. Written informed consent obtained. Footwear: Conventional shoes (Skechers Go Walk 4.0-Pursuit for females; Superior 2.0-Jeveno for males); Minimal shoes (Vivobarefoot Primus Knit; wider sole, shore hardness 75); Barefoot. Fitting ensured 0.5–2 cm toe room; participants blinded to hypotheses. Outcomes: - Postural stability: Center of pressure (CoP) movement during quiet standing with eyes open/closed, measured on a pressure plate (FootWork Pro; 490×490×7.6 mm; 4,096 sensors; 40 Hz). Three 30-s trials each condition. Metrics: mean CoP velocity (mm/s) and max range of CoP (mm) in AP and ML directions. Lower values indicate better stability. Data filtered (4 Hz low-pass Butterworth, zero-lag) and averaged over trials. - Walking stability: Margin of Stability (MoS) in AP and ML at heel contact during over-ground walking, captured with 12-camera motion-capture (200 Hz; Oqus-7, Qualisys). Base of support defined by toe (AP) and calcaneus (ML) markers; XCoM computed from pelvis markers’ CoM position and velocity. Mean MoS averaged over all steps per condition. Walking tasks: normal walking and dual-task walking (counting backwards). Trials at self-selected speed; 6–8 trials per task per condition. 3D data low-pass filtered at 20 Hz. - Mobility: Timed Up and Go (TUG; seconds; shorter is better) and modified Star Excursion Balance Test (SEBT) with four directions (anterior, posterior, medial, lateral); mean of three trials; longer reach is better. - Perceptions: Monitor Orthopaedic Shoes questionnaire (100-mm VAS) for attractiveness, attractiveness for others, comfort, fit, ease of donning/doffing, weight, and perceived stability (completed for shoe conditions only). Protocol: Two blocks. Block 1 included posturography and mobility in all footwear; Block 2 included walking tasks and shoe perceptions in all footwear. Acclimatization: ten 10-m walks before testing each new footwear condition; rest breaks provided. Statistical analysis: Data inspected for normality; CoP outcomes log-transformed due to skewness. Linear mixed-effects models with participant as random intercept and first-order autoregressive covariance. Fixed effects: footwear and visual condition for postural stability; footwear and walking condition for walking stability; footwear for mobility. MoS AP adjusted for speed and cadence; MoS ML adjusted for speed. Interaction terms tested (footwear×visual; footwear×walking). Post hoc pairwise comparisons with Bonferroni corrections. Paired t-tests compared perceptions between conventional and minimal shoes. Significance p<0.05. Software: SPSS v25.

Participants: n=30; mean age 68.6±4.4 years; height 1.68±0.08 m; weight 75.5±13.6 kg; BMI 26.6±3.7 kg/m²; 57% female. Postural stability: Main effects of footwear on all CoP metrics (p<0.050). Minimal shoes and barefoot showed significantly lower CoP velocity and range (better stability) than conventional shoes; no significant differences between minimal and barefoot. Visual condition affected AP CoP velocity (eyes open better than eyes closed; p<0.001) but not other metrics. No footwear×visual interaction. Walking stability: Main effect of footwear on AP MoS (p<0.050); minimal shoes yielded higher AP MoS (better stability) than conventional (p<0.001) and barefoot (p<0.001). No main effect on ML MoS. Walking condition (normal vs dual-task) had no significant main effect on AP or ML MoS and no footwear×walking interaction. Adjusting for speed and cadence did not alter the AP MoS footwear effects. Mobility: Significant footwear effects for TUG and SEBT in all directions (all p<0.050). TUG times were lower (faster) in minimal shoes versus conventional and barefoot by approximately 0.3 s (p=0.001 vs each). SEBT reach distances were greater in minimal shoes than conventional and barefoot in anterior, posterior, lateral, and medial directions (differences ~1–4.4 cm; all p<0.050). Perceptions: Compared with conventional shoes, minimal shoes were rated as better fit (mean difference 16.0; p=0.004), lighter (mean difference −9.1; p=0.001; lower values=lighter), and more stable (mean difference 21.4; p<0.001). No significant differences for attractiveness, attractiveness for others, comfort, or ease of donning/doffing. Overall: Minimal shoes improved standing and walking stability compared with conventional shoes, independent of visual input or dual-tasking, and improved mobility relative to both conventional and barefoot conditions.

The study addressed whether footwear type influences stability and mobility in older adults with a history of falls and whether these effects depend on visual input or cognitive load. Minimal shoes enhanced postural stability versus conventional shoes and matched barefoot, and improved dynamic walking stability in the sagittal plane (higher AP MoS) versus both conventional shoes and barefoot. These findings align with prior work showing minimalist features can improve stability, and extend them to a higher-risk cohort. Participants’ perceptions of greater stability in minimal shoes corroborate objective findings. No differences were found in ML MoS across footwear, suggesting that sagittal-plane dynamics may be more sensitive to footwear modifications in this context. The lack of moderation by visual deprivation or dual-tasking indicates footwear effects were robust across these conditions, possibly because the tasks were not sufficiently challenging to elicit differential reliance on plantar sensation. Mechanistically, benefits of minimal shoes may derive from reduced heel elevation (preventing anterior CoM shift), less curved soles (reducing rocking), wider soles (larger base of support and increased plantar sensory input), and thinner soles (enhanced cutaneous receptor stimulation). Importantly, AP MoS benefits persisted after adjusting for walking speed and cadence, implying contributions beyond spatiotemporal adaptation. Clinically, improved stability and mobility could translate to reduced fall risk, but real-world and long-term effects require further investigation.

Minimal shoes improved postural stability, sagittal-plane walking stability, and mobility compared with conventional shoes in older adults with a history of falls, and outperformed barefoot for walking stability and mobility. Effects were consistent regardless of visual input or dual-tasking. These results support considering minimal footwear for enhancing stability and mobility in this population. Future work should include longitudinal randomized trials in older and higher-risk cohorts, assess real-world fall outcomes, incorporate more challenging balance and dual-task paradigms, measure plantar sensitivity and proprioception, and test responses to slips/trips to establish mechanisms and generalizability.

- Cross-sectional, laboratory-based study with short exposure to footwear; real-life generalizability is limited. - Participants tested in new shoes despite acclimatization periods; residual novelty effects possible. - Sample relatively young for fallers (mean age 68 years); findings may not generalize to adults >70. - No measures of foot sole sensitivity or lower-limb proprioception, which may mediate effects. - Did not assess slip/trip perturbations that commonly cause falls. - Walking stability tasks and visual deprivation/dual-tasking may not have been sufficiently challenging to reveal moderation effects. - Safe lab environment may not reflect everyday conditions or varied surfaces; thinner soles could increase discomfort risk outdoors.