High heeled shoes - strict no-no or a considered and grown-up decision?
This blog entry discusses the cons and pros of wearing high heels. And this is going to be a dicey blog for me to write. One of the things I learned early on in my professional career is that women (and men for that matter) have no interest in my lecturing at them on why they should not wear high heels. So I’m not going to do that, and further than that I’m going to acknowledge what we already know about why people wear them. Namely that they are fun to wear and make people feel awesome! Well… feel emotionally awesome that is. Feeling awesome physically in heels is, as will be no surprise, another story altogether.
So instead of lecturing I’m going to present this discussion within the context of my professional approach to addressing all bad habits, whether heels, poor posture, a sedentary lifetyle or whatever.
My job as a professional is to educate my client around the likely consequences of any particular habit, place those consequences in the context of the perceived benefits, and then send them off into the wide world to make their own big boy/girl decisions. I will often give my opinion on what I would do in their shoes (pun intended). But in the end It’s all about informed decision making by an empowered and autonomous adult.
Once the decision is made, then it’s my job to support that person through the consequences, good and bad. This is something I’m happy to do and indeed that’s what I get paid to do!
So in this spirit, let’s have a discussion about the consequences of long term high heel use. Now, I’ll be up front and warn you to brace yourself, you know what is coming here. We all know that heels aren’t a healthy habit so the following won’t shock anybody. But if we’re going to make informed decisions than let’s get the information flowing shall we?
So here’s some of the the bad stuff about high heels.
The fundamental problem with high heels is all around foot positioning. They place the foot and ankle in a plantarflexed position. This means that the foot is “pointed” ballet style through the whole gait cycle. At a superficial level, if you want to appreciate why this is a problem, just have a look at a professional ballerina’s feet, they are often broken train wrecks from years of loading in pointe and demi-pointe positions. Lots of love to the ballet community, wonderful athletes… this is simply a consequence of the sport. No different really to concussions being a consequence of football. These athletes will know what I mean.
Simply put, assuming a plantarflexed position through the whole gait cycle for a full day of walking is bad mechanics, and bad mechanics lead to injuries.
Drilling down into the problem a bit further there are a number of areas where these mechanical problems manifest:
The plantarflexed position drives extra load bearing responsibility into the calf musculature and achilles tendon. This tends to thicken and stiffen the achilles and places the calf musculature at greater strain risk. Sadly, with chronic high heel use, the calf musculature can also adaptively shorten, the outcome of which is that even wearing flats becomes painful because of the stretch placed on the -now shortened- calf in flatfoot position!
Foot deformity may be the most unpleasant outcome from long term of long term high heel use. Specifically hallux valgus (Bunions) is a common problem and is likely more associated with heels that have a pointed toe box. Basically the angle of the joint at the base of the big toe changes so that the toe itself migrates to overlap the 2nd through 5th toes. It looks like the picture below. It’s uncomfortable and it impairs normal walking mechanics. Bummer!
Fig 1. Hallux valgus deformity (Image from craryshoes.com/solutions-hallux-valgus/)
The plantarflexed position also places excessive load into the forefoot, which in heels bears a disproportionate amount of weight versus the heel and midfoot. This excessive forefoot loading contributes to metatarsalgia, an umbrella term for pain in the forefoot that can be bone, joint, nerve or muscle (or all of the above) in origin. It also contributes to osteoarthritis of the first metatarsal-phalangeal joint, this is the joint at the base of the big toe where it connects with the rest of the foot, it’s the most common site in the foot for the onset of arthritis. This load pattern can also cause corns and calluses on the foot.
If that weren’t enough, heels are just less stable than flat foot gait. The most common heel related trip to an emergency room is due to ankle sprains (ligament tears) after a fall. We also know that the ankle stabilising musculature is turned on in overdrive mode when wearing heels in an attempt to control the foot, and this may be part of the reason why high heels walking is more fatiguing than when in “flat” shoes.
Great so we know that there is a long and well documented list of risks associated with wearing high heels. No surprises there. And yet we also know that 42% of women who wear high heels habitually, report doing it in pain! So why do it? Why do people love high heels so much and what is the payoff in exchange for the pain and injury of this activity?
I like to use the analogy of smoking. Everyone knows that smoking is a bad health habit, even a smoker will likely agree to that much. But like high heel wearers, smokers get a payoff to smoking. And that, frankly, is that smoking gives a physical high from nicotine that feels great. Granted without saying that the nicotine high is not worth the long term train-wreck of health problems that result from the smoking but to deny the simple short term pleasure that the smoker gets is just silly.
And similarly, as discussed above, and like with smoking, the simple payoff to wearing heels is that people feel taller, sexier, more powerful when wearing them. Humans beings are emotionally driven. So this is an intoxicating benefit that explains the use of heels in the presence of myriad costs discussed above.
As with any habit, good, bad and ugly, perhaps the best approach is moderation. Moderation, just like when applied to cheesecake makes sense when wearing heels as well. How about heels 2days/wk instead of 5? Or how about heels on when going to important meetings but not at other times in the office. During those other times? Some rockin’, stylish and edgy flat shoes that make you feel like a million bucks but don’t compromise the mechanics of your stance and walk!
Here’s an interesting alternative idea for you as well. A group of researchers in Taiwan has published a handful of papers investigating custom made shoe inserts for use in high heels. They are a little clunky and will only work in closed shoes (see the figure below), but their research does show that use of this type of support will redistribute weight from the forefoot, especially at the base of the big toe, over to the midfoot where the foot is better designed to bear it. It’s not a perfect solution but a pedorthist/chiropodist (the professionals who would make such a custom insert for you) may be a point of call for those wishing to mitigate the negative mechanical impact of heels.
Fig 2. High heeled shoes custom insert to distribute load from the forefoot to midfoot, a pedorthist or chiropodist can make this for you (image from Hong et. al. 2005).
Now, my laissez faire approach to high heels is not that of every physiotherapist. My colleague Vanessa here in the clinic is much more hardline against. If you are her client you will likely be told that they are off limits if they are likely to irritate your injury. I like this though, it illustrates that professional physiotherapy care is not one size fits all. Each professional will have their own unique style and approach to a problem. Some of us are better fits for an individual client A and some for an individual client B. Good care involves a match between the client and the professional, and that match is unique for each person and problem.
The next time you consider choosing a professional of any stripe, including physiotherapy consider this insight as you make your choice on who will be taking care of your needs.
And for my purposes in the context of this blog, the next time you throw on your heels, consider the above discussed consequences in your decision making. If you decide against them, great, that’s a healthy personal decision. If you decide to go ahead and wear them anyway, well that’s great too - I support you and look forward to seeing you in clinic!
Further reading (if you really want to impress your friends)
Cronin, N. J. (2014). The effects of high heeled shoes on female gait: a review. Journal of Electromyography and Kinesiology, 24(2), 258-263.
Cronin, N. J., Barrett, R. S., & Carty, C. P. (2012). Long-term use of high-heeled shoes alters the neuromechanics of human walking. Journal of Applied Physiology, 112(6), 1054-1058.
Csapo, R., Maganaris, C. N., Seynnes, O. R., & Narici, M. V. (2010). On muscle, tendon and high heels. Journal of Experimental Biology, 213(15), 2582-2588.
Hong, W. H., Lee, Y. H., Chen, H. C., Pei, Y. C., & Wu, C. Y. (2005). Influence of heel height and shoe insert on comfort perception and biomechanical performance of young female adults during walking. Foot & ankle international, 26(12), 1042-1048.
Moore, J. X., Lambert, B., Jenkins, G. P., & McGwin, G. (2015). Epidemiology of high-heel shoe injuries in US women: 2002 to 2012. The Journal of Foot and Ankle Surgery, 54(4), 615-619.