High Heels, High Risk

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Close to half of US women wear high heels, and those who wear them own an average of nine pairs each. The shoes tend to make a regular appearance even though 71 percent of women surveyed by the American Podiatric Medical Association (APMA) said the shoes hurt their feet.1

When asked what they’d do if the shoes hurt, 38 percent of women confessed they’d continue to wear them anyway if it was a pair they liked. You might assume that the pain you’re experiencing is temporary, and once you take the heels off to give your feet a rub and some time to recuperate, they’ll be back to normal.

High Heel-Related Injuries Doubled in the Last Decade

From 2002 to 2012, more than 123,000 injuries from wearing high heels were treated in US emergency rooms. The amount of such injuries doubled from 2002 to 2012, according to the new research published in the Journal of Foot and Ankle Surgery.2

The majority of injuries (more than 80 percent) involved sprains and strains to ankles and feet, although knees, shoulders, and even heads were also injured. Most of those injured were women between the ages of 20 and 29, and the injuries typically occurred while in the home.

In the majority of cases, the injuries were minor, and one in five resulted in a broken bone. The study’s lead author, Gerald McGwin, an epidemiology professor in the University of Alabama at Birmingham (UAB) School of Public Health, noted:3

“Although high-heeled shoes might be stylish, from a health standpoint, it would be worthwhile for those interested in wearing high-heeled shoes to understand the risks and the potential harm that precarious activities in high-heeled shoes can cause.”

However, over time wearing high heels can lead to chronic problems, not only with your feet but also elsewhere in your body.

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High Heels Change the Dynamics of Human Walking

Even if you manage to avoid an injury such as a sprained ankle while wearing heels, such shoes can actually change muscle activity and the dynamics of normal walking.

High heels (generally described as a heel height of two inches or higher) shift your foot forward into an unnatural position with increased weight on your toes.

Your body tilts forward, so you lean backwards and overarch your back to compensate. This posture changes the normal human gait and adds tremendous strain to your hips, lower back, and your knees.

Researchers found high heels increase bone-on-bone forces in the knee joint significantly, which they said “may explain the observed higher incidence of osteoarthritis in the knee joint in women as compared with men.”4

A 2015 study published in the Journal of Orthopedic Research also found changes to knee kinematics and kinetics during high-heel walking that may contribute to increased osteoarthritis risk in women. The risk increased with extra weight and as the heel height increased.5

Because of the extra stress placed on your knees, wearing high heels increased the risk of joint degeneration and knee osteoarthritis in yet another study as well.6

Other research suggested the use of high-heeled shoes may “alter the natural position of the foot-ankle complex, and thereby produce a chain reaction of (mostly negative) effects that travels up the lower limb at least as far as the spine.”7

Additionally, according to research from the University of Southern California, wearing 3.75-inch heels may increase stress on your knee joints by up to 90 percent compared to wearing a half-inch heel!8

Generally, the higher the heel the more stress it places on your knee joints, however even shoes with moderately high heels (1.5 inch) “significantly increase knee torques” that may contribute to the development and progression of knee osteoarthritis.9

High Heels May Cause Bunions and Musculoskeletal Injuries

Indeed, yet another study revealed wearing high heels may lead to “abnormal spine loading patterns and increases the risk for developing musculoskeletal injuries.”10

And when worn long-term (defined as at least 40 hours a week for a minimum of two years), high heels lead to “substantial increases in muscle fascicle strains and muscle activation during the stance phase compared with barefoot walking.”

The results suggest that long-term high heel use may “compromise muscle efficiency in walking,” which explains why many high-heel wearers complain of discomfort and muscle fatigue.11

Aside from altering your gait, wearing high heels may contribute to bunions (hallux valgus). As written in the journal Deutsches Arzteblatt International:12

“In women it is not only narrow shoes that cause hallux valgus but also higher heels. These result in more weight placed on the forefoot, with overstretching of the toes and resultant splayfoot development, which in turn triggers metatarsus primus varus deformity.”

Up to One-Third of Women May Suffer Permanent Problems

According to the American Osteopathic Association, not only are high heels one of the major factors leading to foot problems in women, but up to one-third of wearers suffer from permanent problems due to long-term use.13 Natalie A. Nevins, DO, an osteopathic physician from Hollywood, Calif. who specializes in neuromusculoskeletal medicine, explained:14

“Extended wear of high heels and continually bending your toes into an unnatural position can cause a range of ailments, from ingrown toenails to irreversible damage to leg tendons.

Additionally, cramming your toes into a narrow toe box can cause nerve damage and bunions… High heels have also been linked to overworked or injured leg muscles, osteoarthritis of the knee, plantar fasciitis and low back pain.”

The unnatural posture that’s created from wearing high heels, which causes you to overarch your back leading to strain on your knees, hips and lower back, can cause even more issues. For instance, it can put pressure on nerves in your back, leading to sciatica, a painful condition that leads to pain and numbness that can travel down to your feet.

Chronic pain is not uncommon with extended wear of high heels. Due to the position of your heel (pointed upward), your Achilles tendon can shorten and tighten. When you switch back to flats, it will stretch again, which can be painful. According to Dr. Nevins:15 “This tendon is designed to be flexible, so the foot can lie flat or point. With repetitive wear, you can develop unhealthy patterns that can persist even when you’re not wearing high heels.”

Are There Healthier Ways to Wear High Heels?

In general, the less you wear high heels, the better. It doesn’t matter if the heel is a stiletto or a wedge… both wide-heeled and narrow-heeled shoes increase pressure on your knees in the places where degenerative joint changes often occur.16 If you do wear high-heel shoes, reserve them for occasions that don’t involve extended periods of walking and standing. Ideally, bring them with you to a special event, put them on when you get there, and then change into your more comfortable shoes when you leave.

Choosing lower heels – 1.5 inches or less – may also help to minimize some of the strain, and it’s also important that the shoes fit properly. Avoid shoes that cause your foot to slide forward, which puts extra pressure on your toes, and choose those with a toe box wide enough to wiggle your toes. Also, consider adding a gel or foam insert to heels you already own, which may act as a shock absorber and help to reduce some of the strain on your knees. Overall, however, one of the easiest changes you can make to avoid knee pain and foot problems is to wear appropriate footwear for all of your daily activities. Opt for comfort over style whenever possible.

It’s Not Only High Heels That Pose a Risk…

High heels are a major offender when it comes to foot pain, but another popular style – flip flops – is also a culprit. Flip-flops may throw off your stride and cause pain in your lower legs and feet, according to researchers at Auburn University in Alabama.17 Researchers recruited 39 college-age men and women and measured how the participants walked on a special platform wearing thong flip-flops. On another day, the same participants walked across the platform wearing their own athletic shoes. When the participants wore flip-flops, they took shorter strides and their heels hit the ground with less vertical force.

When people walk in flip-flops, they apparently alter their gait, which may explain why lower leg and foot problems can occur in people who wear such shoes frequently. Throwing on a pair of flip-flops to putter around your garden or walk along the beach is an integral part of summer for many people. However, according to Tony Bruno — a certified Muscle Activation Techniques Specialist — wearing flip-flops can not only cause dysfunctional changes and pain in your foot, these changes can resonate all the way up to your head, neck, and jaw.18

This happens because your toes try to grip into bottom of the flip-flop to hold them on your feet. Look at your toes in flip-flops. The distal part of your toe is trying to flex down (planter flex) to hold the flip-flop on while the other part of your toe (middle) is trying to bridge up (dorsi flex). Unfortunately, this is the opposite of what your toes should be doing at that time. This improper toe action shortens natural stride, prevents the natural “locking” of your foot, and forces your hip and leg musculature to work harder, forcing some muscles to shut down. Hammer toes are the result of years of compensation from the intrinsic (small) foot muscles and long term flip-flop wear can contribute to this.

So if you want to avoid hammer toes, you may want to reconsider wearing flip-flops. In any event, taking off your flip-flops in favor of walking barefoot on the earth will offer benefits far beyond your foot health, as it will allow your body to be grounded to the earth.

Sources and References
The Journal of Foot & Ankle Surgery May 12, 2015
Scientific American June 7, 2015
Medicine Net June 5, 2015
1 PR Newswire May 19, 2014
2 The Journal of Foot & Ankle Surgery May 12, 2015
3 Medicine Net June 5, 2015
4 J Appl Biomech. 2012 Feb;28(1):20-8.
5 J Orthop Res. 2015 Mar;33(3):405-11.
6 Gait Posture. 2012 Mar;35(3):483-8.
7 J Electromyogr Kinesiol. 2014 Apr;24(2):258-63.
8 Gait & Posture June 2012, Volume 36, Issue 2, Pages 271-275
9 Arch Phys Med Rehabil. 2005 May;86(5):871-5.
10 Man Ther. 2013 Dec;18(6):506-11.
11 J Appl Physiol (1985). 2012 Mar;112(6):1054-8.
12 Dtsch Arztebl Int. 2013 Apr; 110(17): 296.
13, 14, 15 American Osteopathic Association, The Real Harm in High Heels

See also:
Happy Feet: A Simple Soothing Technique
Walking: Primordial Rediscovery