Balancing Act: A real-world approach to high heels

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Balancing Act: A real-world approach to high

http://lowerextremityreview.com/cover_story/balancing-act-a-real-world-approach-\

to-high-heels

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.

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

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. "

Limits

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

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. "

Insoles

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 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. 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

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.

References

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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.

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Lancet 1998; 351(9113):1399–1401.

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7. Stevermer C, N, Gillette J. Varus knee torques in high-heeled stair

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State College, PA, August 2009.

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Lancet 2001;357(9262):1097-1098.

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