To assess the influence of footwear on injury, we prospectively studied all injured children presenting to the Emergency Department of The Children's Hospital of Philadelphia during February, May, July, and October 1988. Information was collected concerning the type and characteristics of footwear worn and environmental factors. Comparisons were made between those involving and those not involving loss of footing (LOF) during injury. Of the 3015 children studied, LOF occurred in 1075 (35.8%). Overall, significantly more injuries involved LOF in children whose feet were covered (n = 946, 37.0%) than in those who were barefoot (n = 129, 29.1%) at the time of injury (P < 0.001). However, children wearing low-top sneakers had the lowest rate of LOF (24.0%) of any group. Children wearing rough-sole footwear had LOF significantly less frequently (24.2%) than those wearing smooth-sole footwear (51.8%; P < 0.001). Rubber-sole footwear was less frequently associated with LOF (n = 488, 28.6%) than were other sole materials (n = 457, 53.8%; P < 0.001). Our data suggest a potential injury prevention strategy involving utilization of rough-sole footwear.