November 2009

Balancing Act: A real-world approach to high heels 6673814 6673814

Every year, it seems, another study reconfirms what practitioners already know: High heeled shoe wear alters biomechanics over time in undeniable, painful ways. But practitioners also know that asking women to give up their heels is an exercise in futility. Instead, they focus on finding a balance.

by Cary Groner

For decades, a legend has persisted that a woman once climbed Oregon’s Mt. Hood wearing high heels. Sometime in the early 1900s, the story goes, this hardy bon vivant slogged upward past the glaciers and hogback ridges, then paused on the summit for a sip of champagne.

As much as people love to believe such tales, this one is probably apocryphal; even if her shoes didn’t fall apart in the snow, the woman would have lost toes to frostbite long before she reached the top, even in summer. Besides, it’s pretty hard to strap crampons onto pumps.

But such stories stay in circulation because, like fables, they tell us something about who we are. A lot of women would confess that even though they haven’t actually climbed a mountain in their heels, they might as well have—it’s just that the peaks in question had more to do with career advancement or attracting a mate than with gale-force winds and ice axes. As a Brazilian friend once said of a favorite pair of stilettos, “My feet may be in hell, but from the ankles up I look like heaven.”

Which helps explain why women keep slipping on the Ferragamos, the Maglis, the Louboutins, or whatever else strikes them as most likely to lead to conquest on a given day—or night. The question for clinicians then becomes not how to get them to give up the shoes (face it; they won’t), but how to contain the damage.

Research suggests that the damage is real, though there is considerable disagreement about how it manifests. A recent paper, for example, drew media attention with its conclusion that past shoewear use in women was associated with hindfoot pain.1 The study raised as many questions as it answered, however. For example, the authors lumped together high heels and sandals as “poor” shoes, even though sandals have a very different biomechanical effect on the foot and are worn daily by billions of people worldwide without deleterious effects. Moreover, the researchers found shoewear associated only with hindfoot pain, but discovered no correlation with pain in the forefoot, ball of the foot, heel, or arch—a finding that, when related to the experts interviewed for this article, provoked frank skepticism. (The paper’s corresponding author did not reply to an interview request.)

Curiously enough, however, a recent paper from Brazil reached a similar conclusion—that prevalence of foot pain while wearing shoes was associated with female gender but not with a history of wearing high heels per se.2 10680578 10680578

Such counterintuitive and perplexing findings notwithstanding, other research has provided insight into the biomechanical issues associated with high heels. For example, researchers in South Korea recently reported that high heels altered the activity of lower-extremity muscles during stair ascent.3 An earlier U.S. study demonstrated that high heels altered plantar flexion, knee flexion, vertical ground reaction force, and braking force.4 Several papers have reported associations between high heel wear and the increased risk of knee osteoarthritis (OA) in women. In one article, high heels increased force across the patellofemoral joint and imposed a greater compressive force on the medial compartment.5 In another, the same researcher found that even shoes with moderately high heels—1.5 inches—significantly increased knee torques considered relevant to the development or progression of knee OA.6 And in a paper presented at the 2009 conference of the American Society of Biomechanics, scientists found that descending stairs in high-heeled footwear increased varus torques at the knee, and that the resulting medial compressive forces could increase risk for knee OA.7

Finding a balance

All of which leads back to the question of balance. Clinicians—many of them female—agree that women are unlikely to give up high heels regardless of the pain that may lie in store down the road. So how do you best inform them of the dangers and convince them to strike a balance? How high a heel is too high? How much wear is too much?

“Like everything in life, it has to do with moderation,” said Glen Pfeffer, MD, director of the Foot and Ankle Center at Cedars-Sinai Medical Center in Beverly Hills, CA. “This season, heels are going up with the Dow—they’re up to four or five inches now, and it’s just common sense that we’re not meant to walk on our toes long-term.”

The problems that clinicians typically associate with excessive high heel wear include neuromas, hammer- and claw toes, bunions, and bone spurs. Pfeffer recommends that patients keep their heels under 2¼ inches and wear higher versions only to brief functions—for a dinner out or a party. He emphasized that although women can often get away with ignoring such advice in their 20s or 30s, it will catch up with them in their 40s and later.

“It has to do with exposure—the number of years that a foot, which is basically square-shaped in the front, is squeezed into shoes that are triangular in front,” he explained. “If you take that mismatch and add a heel, it places a huge deforming force on the front of the foot. A three-inch heel puts on seven times the force that a one-inch heel does, and that’s not healthy.”

Pfeffer emphasized that he’s not against fashion shoes, and that some patients have congenital deformities similar to those acquired from wearing high heels. Nevertheless, he said, to overstress the occasional occurrence of congenital problems does most patients a disservice, because it suggests that they are powerless to prevent trouble.

“If someone understands the etiology of their problem, they can treat it effectively,” he said. “These days, when we are talking about healthcare reform, it gets harder to justify a corrective surgery that is made necessary by our own neglect.”

Pfeffer’s most frequent advice to such patients, other than that already noted? “Stretch your shoes, because shoes that are too small compound high heels’ deforming forces on the forefoot.”

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Naleen Prasad, DPM, who is in private practice at Bay Area Foot Care in Castro Valley and Dublin, CA, said that in her experience the women most at risk for problems related to high heels either have flat feet, very high arches, equinus deformity (a plantar declination of the foot), or a shortened Achilles tendon. The most common complaint she sees in such women is painful forefoot corns and calluses, but issues can be much more serious—including stress fractures.

“I explain to my patients that, biomechanically, there’s a reason their bodies form those corns,” she said. “As women age, the fat pad under the metatarsal heads gets anteriorly displaced, and corns and calluses are some of the body’s responses to the resulting pressure. High heels exacerbate all that.”

Prasad discourages such patients from excessive high heel wear, pointing out that stylish alternatives are available. “I try to convince them to go into supportive shoes, and of course orthoses,” she added. “But orthoses have their limits, and I won’t make them for shoes with a six-inch spiked heel.”

Commuter shoes

The syndromes are the same whether you’re on the West Coast, the East Coast, or somewhere in between.

“I’m a foot doctor, I wear high heels, and I know it’s bad for you,” said Jacqueline Sutera, DPM, who is in private practice in New York City. Sutera’s suggested compromise has evolved in response to the environment in which she practices—Manhattan, where women typically walk long distances on the avenues before and after work.

“What I do every day, and what I preach to my female patients, is have a pair of comfortable commuter shoes,” she said. “Wear flats or running shoes for all those errands, and save the heels for work.”

Not just any heels, however. Sutera recommends heels of three inches or less, and preferably those that are thicker, hence more stable. Although a 2001 study reported that wide-heeled shoes increase peak knee varus torque as much if not more than narrow-heeled shoes,8 most practitioners interviewed for this article said they tend to steer patients toward a chunkier heel.

“The wider the heel, the safer and better it is,” Sutera explained. “For example, I have three pairs of ballerina wedges, which transfer the weight across a wider area.”

Sutera added that it’s important that high heels have a back—and not just a sling back.

“Slides are bad news,” she said, “because now, on top of your skeleton having to hyperextend backward and your foot being loaded with a lot of weight in the front, your toes have the extra job of gripping the shoe so it doesn’t go flying off.”

Overweight women compound such problems, Sutera said, and in her experience are more prone than others to stress fractures, neuromas, bunions, bone spurs, and toe injuries. Women with flat feet, and the associated extra joint motion, are also at increased risk.

Sutera encourages patients to do exercises to relieve symptoms. One involves placing a towel or other object on the floor, picking it up with the toes, holding it for about 10 seconds, then switching to the other foot. This strengthens the foot’s small intrinsic muscles, which usually don’t get much exercise due to shoe wear, but which are important stabilizers.

Sutera added that over-the-counter devices such as toe spreaders can also help alleviate symptoms, but emphasized that nothing, including exercises, actually corrects deformities. That requires surgery.

“I’m pretty candid with my patients,” she noted. “I show them pictures of what their feet are likely to look like if they don’t change. When they start saying, ‘Oh yeah, my aunt and my grandma and my mom all had bunions and needed surgery,’ they realize there’s a pretty good chance they’ll need it too. Some people have a genetic predisposition for such problems, but environmental factors—the choices you make regarding activity and footwear—are critical.”

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One choice favored by clinicians is some form of orthosis or shock-absorbing insole, but the slender lasts used for high heels make such accommodations especially difficult to design and produce.

“It isn’t easy to make orthoses fit because dress shoes are so shallow in the heel,” said Robert Schwartz, CPed, who also practices in New York City. “When you add that extra layer, it lifts the foot and makes it hard to keep it in the shoe when walking.”

Schwartz addresses the problem by gluing orthotic components into the shoe rather than fabricating a removable device. The downside, of course, is that a woman will need a separate pair of orthoses or insoles for every pair of shoes. Given that a 2007 ShopSmart survey found that the average American woman owns 19 pairs of shoes, that’s a lot of insoles.

Jarret Reinhartz, CPed, in private practice in Miami, agrees that it’s a vexing problem.

“A lot of women wear high heels that are too small, and their toes and feet wind up conforming to the shape of the shoe, so there isn’t room to do much pedorthically,” he said.

If women buy shoes that are big enough and have a removable foot bed, however, addressing the situation is easier.

“The stock insole may not be that substantial, but if the manufacturer has allowed for it in the design of the shoe, we can replace it with something better,” Reinhartz said. “Usually I try to offload problem areas of the forefoot with a metatarsal pad, and some of the gels work well. But if women really want to be comfortable, I urge them not to wear heels at all.”

Some newer products may hold promise. Howard Dananberg, DPM, in private practice in Bedford, NH, has developed an insole that, he claims, helps redistribute some of the forces backward onto the heel.

“In-shoe pressure testing shows that with a 2¾ inch heel, 70 percent of your weight is on the front of the foot,” Dananberg said. “As you move forward and upward, you transfer the heel load to the front, and to accommodate that, you plantar flex the ankle. The narrow part of the talus then slides into the joint, making it increasingly unstable.”

The insole he’s designed helps tip the talus backward in the mortise, he said. Testing indicates that as a result, when the insole is worn with a two-inch heel, the increase in forefoot pressure is roughly one-third of the increase seen without the insole.9

“It doesn’t work for everybody,” Dananberg acknowledged, “but about 80 percent of wearers get a significant positive outcome. Women are going to wear high heels regardless of what a podiatrist tells them, so I think we should be practical and make it optimal biomechanically.”

The Last Resort 3638288 3638288

When less drastic measures fail, of course, surgeons get involved. Decisions about surgery depend on the individual patient, and as noted earlier, surgeons increasingly take a conservative approach.

“I start patient with simple over-the-counter inserts and metatarsal pads,” said Judith Baumhauer, MD, a professor in the division of foot and ankle surgery at the University of Rochester Medical Center in upstate New York. “There are no natural history studies to say that if you don’t have surgery early on, you’ll progress to a degree requiring more significant surgery. But if people feel like they can’t accommodate their problems and still have a life, then it’s time to talk about an operation.”

Patients reach a point of no return because of the nature of feet, Baumhauer explained. Metatarsal fat pads thin out with and don’t regenerate. Women’s hormone balances are different at age 50 than at 20, and such factors affect how muscles, tendons, and ligaments respond to stress.

What really burns Baumhauer’s bacon, however, has more to do with sociology than physiology: employers who insist that women wear high heels in order to look professionally dressed.

“I hear that and I’m thinking: What is professional?” she said. “It’s hard to believe, but I’ve been asked to write my patients a doctor’s note so they can wear flats to work!”

But at least it works

The good news for women who ultimately require surgery is that it helps.

“All of my patients go back to some type of fashionable shoe, though about half of them stay away from the really high heels,” said Pfeffer, of Cedars-Sinai.

He said that even if patients do return to wearing higher heels, they can do so with significantly less discomfort because after surgery the feet are better shaped for shoes, and biomechanical forces are more balanced. And although recidivist patients suffer a higher incidence of repeated bunions and related issues, Pfeffer said such problems are unusual.

“It’s very rare that I’ll have to reoperate,” he said. “I think people just don’t want to go through it again. They’ll tell me, ‘I’ve been there and done that. I don’t need anything more than a 2½ inch heel!’”

Cary Groner is a freelance writer in the San Francisco Bay Area.


1. Dufour AB, Broe KE, Nguyen US, et al. Foot pain: Is current or past shoewear a factor? Arthitis Rheum 2009;61(10):1352–1358.

2. Paiva de Castro A, Rebelatto JR, Aurichio TR. The relationship between foot pain, anthropometric variables and footwear among older people. Appl Ergon 2010; 41(1):93–97.

3. Yoon JY, An DH, Yoo WG, Kwon YR. Differences in activities of the lower extremity muscles with and without heel contact during stair ascent by young women wearing high-heeled shoes. J Orthop Sci 2009;14(4):418–422.

4. Ebbeling CJ, Hamill J, Crussemeyer JA. Lower extremity mechanics and energy cost of walking in high-heeled shoes. J Orthop Sports Phys Ther 1994;19(4):190–196.

5. Kerrigan DC, Todd MK, Riley PO. Knee osteoarthritis and high-heeled shoes. Lancet 1998; 351(9113):1399–1401.

6. Kerrigan DC, Johansson JL, Bryant MG, et al. Moderate-heeled shoes and knee joint torques relevant to the development and progression of knee osteoarthritis. Arch Phys Med Rehabil 2005; 86(5):871–875.

7. Stevermer C, Nelson N, Gillette J. Varus knee torques in high-heeled stair descent. Presented at American Society of Biomechanics 2009 annual meeting, State College, PA, August 2009.

8. Kerrigan DC, Lelas JL, Karvosky ME. Women’s shoes and knee osteoarthritis. Lancet 2001;357(9262):1097-1098.

9. Dananberg H, Trachtenberg G. High heel design puts less pressure on forefoot. BioMechanics 2000;7(2):75-80.

3 Responses to Balancing Act: A real-world approach to high heels

  1. Pingback: Current issue posted « Lower Extremity Review

  2. Lyle Nalli, DPM says:

    This issue brings up a topic that is nearly impossible to standarize. I have patients over the years in which high heels have either helped their ailment, aggravated on or did neither.
    I belive that shoes, heeled or not, are a catalyst to care( good or bad) and not a cause of pathology.
    The fundamental underlying biomechanical alignment of an individuals foot si the true cause of their patholgy.

    Countless times, folks have told me how high heels caused bunions. Yet, when I ask them to work that backwards ( those who have bunions wore high heels) they faulter. How does one explain bunions of naitves that don’t wear shoes? Or of women who wear high heeled shoe their whole life the the toes are straight (no bunions,neuromas or hammertoes.

    The shoes are truly external or secondary to the causes of these pathologies.

    Lyle Nalli, DPM
    Long Beach, CA

  3. Pamela Doetschman says:

    Very informative. I thoroughly enjoyed the presentation.

    Let me share that I am over 60 and was accustomed to wearing heels between 3 & 4 inches each day for more than 8 hours. Now, I have had to change that pattern – wearing flat, sneaker-like Mary Janes for work as a sales associate. I still wear my high heels, but for very few hours and in circumstances that allow for far more sitting than standing or walking.

    Yes, I have pain in my right knee joint and wonder how much longer I will be able to wear heels before the knee does me in. The primary reason that I switched to the Mary Janes was to hopefully extend my high heel life to my mid 70s.

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