The biomechanical implications of high-heeled shoes are well known, and now dramatic weight-bearing images and new study findings are taking practitioner and patient awareness to the next level. But many women are still sacrificing their feet for fashion.
By Emily Delzell
Marilyn Monroe famously (and perhaps apocryphally) said, “I don’t know who invented high heels, but all women owe him a lot.”1 Foot and ankle practitioners aren’t likely to agree, though high heels have certainly been responsible for more than a few revenue opportunities.
What Marilyn knew, and many other women have found, is that there is probably no other fashion item with the transformative power of high heels—they can instantly confer height, sexuality, authority, confidence, and status.2,3 And, yes, pain. High heels are the number one cause of shoe-related foot pain, and 71% of heel-wearers say they hurt when they wear them, according to a 2014 American Podiatric Medical Association survey of 1000 US adults.4
Metatarsal pain, exacerbation of existing conditions such as bunions and bunionettes, neuromas, capsulitis, balance problems, and ingrown toenails, calluses, and corns are among the common heel-related problems seen by Grace Torres-Hodges, DPM, in her private practice in Pensacola, FL.
Foot and ankle surgeon Michael J. Cornelison, DPM, FACFAS, pinpoints gastrocnemius equinus as a major player in the symptoms that bring heel-wearing patients to his practice in Cupertino, CA.
“We identify equinus as a factor in biomechanical issues with the feet even in the absence of wearing high heels, problems that can include overpronation in the foot, plantar fasciitis, pain in the joints of the midfoot, and other types of tendinitis,” he said. “If people spend most of their time ambulating in high heels, their dorsiflexion is diminished because their heels aren’t ever reaching the ground, and certainly preexisting equinus can be exacerbated by regular use of high heels, or it can be created in a patient who hasn’t had equinus before if they select high-heeled shoe gear most of the time.”
Both Cornelison and Torres-Hodges are sympathetic to their patients’ desires to wear fashionable footwear—and to the need for career-appropriate shoes, which for women in many business settings often means heels.
“I’m not totally anti-heel, but the key is moderation and understanding that the foot is not designed to wear a shoe, and that when you put on something like a heel, you’re forcing it to conform to a shape it was never meant to function in,”
Although many consequences of regular high-heel wear are well known, researchers and clinicians, who understand that women aren’t likely to trade their Louboutins for, say, a sturdy yet supportive walking shoe anytime soon, continue to study the biomechanical implications.
New technology is giving practitioners a 3D view of the foot in high heels, and the pictures aren’t pretty (Figure 1).
Orthopedic surgeons at the Royal National Orthopaedic Hospital in London, UK, have been using a 3D computed tomography (CT) scanner that has a lower radiation dose than traditional CT to assess the ankle and foot while patients are weight bearing and in some cases wearing shoes. They routinely use the 3D scanner to assess patients with flat feet or arthritis to assess deformity and monitor the success of surgery. They also scan patients considering hallux valgus surgery, to look for arthritis in the toe.
“The scans provide new information on how the body works in a standing position that previously was not available,” said Andy Goldberg, MD, MBBS, FRCS (Tr & Orth), a consultant orthopedic surgeon and deputy director of Research & Development at the Royal National Orthopaedic Hospital.
“It has long been known that in hallux valgus or bunions the relationship between the metatarsal head and the sesamoids is altered,” he said. “The sesamoid bones should sit underneath the metatarsal head, while in hallux valgus the big toe drifts off the sesamoids and the tip of the big toe points outwards, but our research has shown that in many cases the cartilage is worn, which in essence is localized arthritis, and we believe that this could affect the outcome of surgery.”5
Images suggest that high heels create similar forces.
“In high heels the big toe is forced into a position that mimics hallux valgus and hence leads to abnormal stresses on the sesamoid joints and, with time, can lead to wear and tear of the shock-absorbing cartilage,” Goldberg said. “Our scans of the foot in high heels have shown how the body’s center of gravity is shifted forward and all the weight is placed on the sesamoids. In addition, the lesser toes are all clawed when wearing high-heeled shoes, which gives rise to the forerunner of hammertoes.”
In the Netherlands, radiologists studying forefoot inflammation in rheumatoid arthritis noticed a number of their healthy control participants came in for their magnetic resonance imaging (MRI) studies wearing heels.
“Some of them had arthritis-related abnormalities on their images and we wondered whether wearing heels affected MRI results,” said Wouter Stomp, MD, a radiology resident at the Leiden University Medical Center.
Stomp and his colleagues asked three young women (aged 17-18 years) to spend a day in flat shoes and a day in heels (mean height, 3.5 inches), taking MRIs of their forefeet after nine hours of wear. The women walked 6.7, 6.1, and 6.5 km, respectively, in flat shoes and 8.1, 7, and 7.1 km, respectively, in heels, including an average of 15 minutes of stair climbing in both shoe conditions.6
Although the researchers consistently identified plantar subcutaneous edema in the medial forefoot after heel wear, they didn’t detect bone marrow edema or deep soft tissue abnormalities.
“Based on this admittedly very small study, we do not expect this [arthritis-related abnormalities] to be caused by short-term effects of high-heel usage and volunteers do not need to be asked to wear flat shoes before undergoing MRI,” he said. “Long-term effects are unknown, though.”
The Dutch researchers did find that their participants, though accustomed to wearing heels and in their own shoes for the study, experienced a lot of pain after a day in heels. Visual analog scale (VAS) pain scores on the day participants wore flat shoes ranged from 0 to 2, but jumped to between 5 and 8 by the end of their day in heels.
Relief for aching feet
Trying to get patients out of their offending shoes is typically the first step in treating metatarsalgia for Megan Leahy, DPM, who says it’s probably the most common heel-related problem she sees in her patients at the Illinois Bone & Joint Institute in Chicago.
She acknowledges that this isn’t always easy.
“Many are in enough discomfort that they’re ready to make a switch, but some are unwilling—I’ve been told, for example, that all their pants are hemmed for a certain heel height and it’s not practical to switch to a lower style,” she said.
Goldberg said he sometimes shows patients who have or are at risk for heel-related problems an educational video he produced that includes 3D weight-bearing scans of a foot in high heels (http://youtu.be/ykAo4DGCjxA).
“As the standing CT scan involves radiation, it is difficult to justify scanning every patient as part of the educational process on better fitting shoes, but do I play the video to them of the foot in high heels, and in most cases they can see that this would apply to them,” he said. “Patients have asked to be scanned just to see their feet in their high heels, but in most cases I explain that we cannot justify [exposure to] ionizing radiation. If, however, I have a complex case where they have specific pain whilst wearing a particular shoe, then I organize a scan in their shoes to get to the bottom of it, but these are cases where there is specific pathology being looked for, and not just uncomfortable high heels.”
For patients who are hanging onto heels, Leahy counsels them to look for features that can take off some of the pressure.
“Wedged heels provide more surface area and a more stable base, and patients can sometimes more comfortably wear heels of a height that would be painful if they were in a stiletto,” she said. “A forefoot platform can also give you height without subjecting the foot to the acute angle of heels without a forefoot lift.”
A study of 15 experienced heel-wearers who walked barefoot and in narrow-heeled shoes of three heights (3.9, 6.3, and 7.3 cm) found that the reduced base but not the heel height reduced normalized walking speed and also led to a reduction in frontal center of mass and center of pressure inclination angles.7
Cornelison tries to recommend reasonable high-heel alternatives to his patients, such as limited wear, lower heels (1.5 inches and below), and shoes with accommodative toe boxes. But he noted that, while forefoot platforms may solve some problems, they could create others.
“The shoes [with forefoot platforms] are often quite bulky and heavy, and this could result in rapid fatigue as someone ambulates; they may also be more prone to taking a misstep, which can cause ankle sprains and fractures,” he said.
Platforms may also curtail forefoot flexibility and sensory input to the plantar surface.
“Unless platform shoes have a rocker built into the forefoot you’re not going to undergo normal gait mechanics, especially in the propulsive phase of walking when you push off the foot,”
he said. “And some of these shoes are so thick and so rigid they have no transference of sensory input, and that could create problems, whether that’s finding the pedal of a car or maintaining proprioception.”
Torres-Hodges noted that some high-heel designers are taking points from athletic shoe manufacturers.
“Some more fashionable shoe choices now use materials more typically found in running shoes, and have merged their mechanical features to create a cushioned outsole that is rubberized, has more give, and may improve load on pressure points,” she said.
Cole Haan, for example, has incorporated Nike’s Air technology, which is pressurized air put inside a tough, flexible bag placed under the heel, forefoot, or both, into several lines of men’s and women’s shoes, including women’s pumps.
Shoe designer Silvia Fado is merging architecture and functional design principles with high-fashion footwear, and has created a fantastical, futuristic line of high heels (Figure 2). The Kinetic Traces line, a prototype line she is using as a basis for designs for more wearable shoes, incorporates springs, rubber balls, pneumatic hydraulics, and metal rings into high-fashion heels to improve comfort and impact absorption.
Fado, who is based in Barcelona, worked with an architect and an engineer to create the shoes, which were made using a combination of traditional and high-tech methods, including leather and metal work, traditional machining, wood shaping, and 3D milling and printing. The Kinetic Traces line is on exhibit at the Dutch Design Week event in Eindhoven, the Netherlands, through October 26. Fado expects to vend a commercial line based on the shoes on her website, silviafado.com, and in some high-end stores in the UK in the next year or so.
For patients wearing lower-tech heels, Torres-Hodges, Leahy, and Cornelison said over-the-counter pads and gel insoles are a reasonable way to reduce heel-related pain.
“I make sure the patient understands that it’s not a fix for the problem such that they could wear heels all the time, but perhaps it’s going to help to avoid symptoms and facilitate the use of a high-heel shoe from time to time—but I stress that this should not be the predominate shoe that they wear,” Cornelison said.
For practical reasons, custom foot orthoses are prescribed less frequently for use in high-heeled shoes, Leahy said.
“We can make orthotics for high heels, but they aren’t as effective as an orthotic for a running shoe because we simply can’t fit as much into heels. This limits their functionality, and the bulk [of the orthosis] can itself be a problem,” she said. “Sometimes for patients with capsulitis I’ll prescribe a custom device with a metatarsal pad to ease pressure and inflammation.”
High heels are an even greater concern for people with diabetes, said Bob Thompson, CPed, executive director of the Institute for Preventive Foot Health.
“Any kind of shoe that causes friction and rubbing, smashes the toes together—as is common in pointy-toed stilettoes—or creates pressure at the ball of the foot is a potentially serious problem for people with diabetes,” said Thompson, who specialized in care of the diabetic foot before he retired from clinical practice in Birmingham, AL, in 2007.
Patients with diabetic neuropathy may not notice small injuries to the foot, and these can quickly become infected and potentially lead to amputation, said Thompson, who noted that he also advised patients with diabetes who did not have any foot or neuropathic symptomology to avoid heels completely.
“I tried to impress upon them—and particularly on younger patients with diabetes, who often think they are invincible—that the person with
diabetes is always one-hundred percent at risk for potential injury to their foot, because even a tiny injury, if left untreated, could result in an amputation in a short period of time,” he said.
For habitual wearers of high heels who are in so much pain that it interferes with their daily life and activities, surgery is considered, Torres-Hodges said.
“Surgery gives a lot of hope and good results, though realistically, people can’t return to wearing five-inch heels,” she said. “They can, however, often wear a more reasonable heel [1.5-2 inches].”
The mainstream media has recently reported on a trend dubbed “Cinderella surgery,” which can include removal of bunions and other prominences, as well as toe shortening or straightening.8,9
Cornelison noted that most of the Cinderella surgeries are combinations of established procedures that would otherwise address typical forefoot deformities such as painful bunions or hammertoes, but are done for the purpose of beautifying the foot or fitting into high fashion shoe gear.
“There’s sort of a gray zone between what is considered reasonable and necessary and surgery to facilitate a fit into whatever the term ‘normal shoe gear’ should mean,” he said. “It becomes a bit of an individual determination depending on one’s lifestyle and what they do, whereby to be comfortable and successful they need to wear certain shoes, and the wearing of those shoes produces pain and problems that to some extent could be fixed surgically. But doing those surgeries solely so someone can fit into a stiletto or simply to beautify the foot is not something most surgeons would advocate or feel comfortable doing.”
Some clinicians have also tried to restore fat pads worn away by age or high-heel use with injectables, including collagen, silicone, and saline, said Leahy, who doesn’t see this as a practical solution.
“Once you lose that fat, you can’t really duplicate it with an injectable, at least not permanently, so those injections need to be repeated every three to four months,” she said. “I don’t do procedures simply to get people back into heels.”
Recent studies highlight the many negative side effects of regular high-heel wear, including impaired lower limb venous return;10 center of mass displacement that results in compensatory changes such as increased knee flexion and lower limb muscle activity;11,12 and shortening of the calf muscle fibers leading to Achilles tendon stiffness and reduced ankle range of motion.12,13
Researchers have looked for a definitive link between high-heel wear and development of osteoarthritis (OA), but have yet to prove a causal association, said Daniel McWilliams, PhD, a postdoctoral research fellow in the Division of Rheumatology, Orthopaedics and Dermatology at the University of Nottingham in the UK.
In a case-controlled study, McWilliams and colleagues used data from participants of the GOAL (genetics of osteoarthritis and lifestyle) study, including an additional questionnaire on specific shoe use per decade of life; 1551 GOAL participants responded to the footwear questions.14
“Our main finding was a lack of association between knee OA or hip OA and recalled footwear use through early adult life,” said McWilliams, whose study found that persistent high and narrow heel wearers had significantly less risk of knee and hip OA.
“The effects of confounding factors, such as previous joint injury, high BMI, and others, appeared to explain the observation that women with OA were less likely to have used high or narrow-heeled shoes. An interesting additional observation was that women with knee or hip pain may have changed their pattern of shoe use to try and improve their joint pain,” he said.
He noted that the findings of the study, which was epublished by BMC Musculoskeletal Disorders in September, relied on the recall of participants, which may have introduced bias into results.
Neil J. Cronin, PhD, who authored a review of studies on the acute and chronic effects of high heels on gait in young, healthy women published in April in the Journal of Electromyography and Kinesiology, noted that most studies of the effects of high heels are limited by their size.15
“From a scientific point of view, a major outcome of my review was that the studies examining the effects of high heels often include very small sample sizes, only investigating around ten to fifteen women. This is probably clouding the picture a lot, because different people respond to shoes in different ways, and also have widely different shoe-wearing habits,” said Cronin, who is a senior researcher at the Neuromuscular Research Centre at the University of Jyväskylä in Finland. “There is clearly a need for much larger, more comprehensive studies that can account for these variations in the way different women use high heels.
He noted that one area particularly worthy of further study was the suspected link between OA and high-heel use.
“This condition is already known to be more prevalent in women than men, so there is a need to understand the factors that cause this trend before we can really address successful prevention,” he said.
Educating patients about the known and suspected risks of high-heel use is a priority for Michael Cornelison.
“I encourage patients to not feel like they have to abandon a fashion shoe altogether, but certainly to understand that there should be very limited times that they are using these shoes,” he said. “I make sure they can make an informed decision—much as if we were talking about doing surgery—so they understand the risk factors involved and recognize what their own expectations are.”
- Marilyn Monroe Quotes. About.com website. http://womenshistory.about.com/cs/quotes/a/marilyn_monroe.htm. Accessed September 28, 2014.
- Kunzle D. Fashion and Fetishism: Corsets, Tight-Lacing, and Other Forms of Body-Sculpting. Thrupp, UK: Sutton Publishing Limited; 2004.
- Wade L. High Heels Hurt Like Hell: Do Women Wear Them to Signify Class and Status? AlterNet website. http://www.alternet.org/high-heels-hurt-hell-do-women-wear-them-signify-class-and-status. Published February 28, 2013. Accessed September 28, 2014.
- Edge Research. Public Opinion Research on Foot Health and Care: Findings from a Survey of 1000 US Adults. American Podiatric Medical Association website. http://www.apma.org/files/APMA2014TodaysPodiatristSurveyAllFindings.pdf. Published March 2014. Accessed September 28, 2014.
- Welck M, Cullen N, Singh D, Goldberg A. The metarsosesamoid “empty crista sign” – could this be a predictor of deformity recurrence after hallux valgus surgery? Presented at the joint International Federation of Foot and Ankle Surgery and American Orthopaedic Foot and Ankle Society meeting, Chicago, September 2014.
- Stomp W, Krabben A, van der Helm-van Mil A, Reijnierse M. Effects of wearing high heels on the forefoot: an MRI evaluation. Scand J Rheumatol 2014;43(1):80-81.
- Chien H, Lu T, Liu M. Control of the motion of the body’s center of mass in relation to the center of pressure during high-heeled gait. Gait Posture 2013;38(3)391-396.
- Women go under the knife for Cinderella surgery. ABC13 Eyewitness News website. http://abc13.com/health/women-go-under-the-knife-for-cinderella-surgery/208447/. Published July 28, 2014. Accessed September 28, 2014.
- Cute Name, Terrifying Procedure: ‘Cinderella’ Plastic Surgery Is on the Rise. Elle website. http://www.elle.com/news/beauty-makeup/women-feet-surgery-stilettos. Published April 24, 2014. Accessed September 28, 2014.
- Tedeschi Filho W, Dezzotti NR, Joviliano EE, et al. Influence of high-heeled shoes on venous function in young women. J Vasc Surg 2012;56(4):1039-1044.
- Blanchette MG, Brault JR, Powers CM. The influence of heel height on utilizedcoefficient of friction during walking. Gait Posture 2011;34(1):107-110.
- Simonsen EB, Svendsen MB, Nørreslet A, et al. Walking on high heels changes muscle activity and the dynamics of human walking significantly. J Appl Biomech 2012;28(1):20-28.
- Csapo R, Maganaris CN, Seynnes OR, Narici MV. On muscle, tendon and high heels. J Exp Biol 2010;213(Pt 15):2582-2588.
- McWilliams DF, Muthuri S, Muir KR, et al. Self-reported adult footwear and the risks of lower limb osteoarthritis: the GOAL case control study. BMC Musculoskelet Disord 2014;15(1):308.
- Cronin NJ. The effects of high heeled shoes on female gait: a review. J Electromyogr Kinesiol 2014;24(2):258-263.