Last week I introduced this column by noting that the injuries I operate on most are not freak accidents — they are predictable failures of the interface between a person and their environment. This week I want to make that concrete with the category I see most consistently overlooked: footwear.
I am not talking about athletic performance optimization. I am talking about the basic mechanical interface between a person and whatever surface they are standing on — and how often that interface is chosen based on appearance, habit, or cost rather than any meaningful assessment of the environment they're entering.
"Every fall prevention conversation is also a hand and wrist injury prevention conversation. Your hands go out first — which means what is on your feet determines what ends up on my operating table."
— Dr. Ben Levine, MDWhy hand surgeons care about what's on your feet
Consider what I actually see in the operating room as a consequence of footwear failures. Wrist fractures from falls on wet dock surfaces — the same FOOSH mechanism we covered in Issue 2 — where the deck was slippery and the footwear had no grip pattern suited to wet conditions. Hand lacerations from fishing deck falls where the momentum of an uncontrolled slip drove hands into hardware. Distal radius fractures from river crossings in trail runners with smooth, worn soles. Scaphoid fractures from jetty falls in flip flops.
The upper extremity bears the brunt of fall trauma because we throw our hands out instinctively to protect ourselves. This is not a reflex you can override — it's hardwired. Which means every fall prevention conversation is, by definition, also a hand and wrist injury prevention conversation. What is on your feet directly determines what ends up on my operating table.
The OR/OR standard: how I evaluate gear
Operating Room / Outdoors: The OR/OR Standard
After nearly three decades in the OR operating on preventable injuries, I stopped seeing gear choices as personal preferences and started seeing them as clinical decisions made outside the hospital. The standard I apply: would this choice be defensible if I had to explain the injury mechanism to another surgeon? That's the OR/OR standard. It applies to footwear the same way it applies to flotation devices and layering systems.
The Alaska environments: four different problems
The Alaska trip concentrates the footwear decision-making problem because the environments we'll move through each present distinct traction and stability requirements. There is no single solution that addresses all of them — which is itself a planning consideration.
Wet Boat Deck
Requires non-marking rubber with an aggressive lug pattern. Sole compound matters more than lug depth — soft rubber grips wet fiberglass and aluminum better than hard rubber with deep lugs. The XtraTuf boot with its classic outsole is the reference standard in this environment for a reason.
Fly Fishing River
Wet polished rock is arguably the most treacherous surface in outdoor recreation. Felt soles grip algae-covered rock better than rubber — which is why felt wading boots remain controversial (environmental transfer of invasive species) but functionally dominant. Rubber with aggressive studs is the best compromise.
Glacier / Mixed Terrain
Ankle support becomes the primary variable on uneven terrain. A stiff-soled boot with genuine ankle support — not a high-top sneaker — changes the biomechanics of an ankle roll significantly. The relevant question is not "can I walk in these" but "what happens during an unexpected lateral load."
Rain-Slicked Boardwalks
Southeast Alaska's rain-soaked wooden boardwalks — found throughout Ketchikan, Wrangell, and Petersburg — become slick surfaces that punish smooth or worn soles. This is the environment where everyday footwear fails most predictably, and where I see the most unnecessary falls among visitors.
How to evaluate any piece of footwear: the four questions
These are not complicated questions. They take about two minutes to think through before a trip. The injury that results from skipping those two minutes takes two to four months to recover from — if it goes well. These are engineering decisions masquerading as fashion choices, and I intend to keep making the former.
This came from The Form & Function Brief.
Every Tuesday — one clinical question answered, one condition explained, one piece of gear worth knowing about. Five minutes. Evidence over ego.
Subscribe Free →- Menant JC, Steele JR, Menz HB, Munro BJ, Lord SR. Optimizing footwear for older people at risk of falls. Journal of Rehabilitation Research and Development. 2008;45(8):1167–1182. doi:10.1682/JRRD.2007.10.0168
- Tencer AF, Koepsell TD, Wolf ME, et al. Biomechanical properties of shoes and risk of falls in older adults. Journal of the American Geriatrics Society. 2004;52(11):1840–1846. doi:10.1111/j.1532-5415.2004.52507.x
- Koepsell TD, Wolf ME, Buchner DM, et al. Footwear style and risk of falls in older adults. Journal of the American Geriatrics Society. 2004;52(9):1495–1501. doi:10.1111/j.1532-5415.2004.52412.x