For centuries, women have worn shoes with heels.
Over this time, however, shoe styles have changed and evolved in a variety of ways to accommodate the demands of fashion trends, with the highest of heels measuring approximately 5 inches. While fashion has dictated societal choices regarding footwear, the anatomical structure and function of the foot has not changed. This has led to corresponding alterations in gait patterns and is a direct correlate to some foot conditions.
As shoe fashion has morphed, the age of the average wearer and the frequency of wearing heels has also changed. A survey performed on footwear choices found that slightly more than 60 percent of American women wear heels greater than 2 inches in height regularly and on average own nine pairs of heels, with a majority reporting pain.1
Shoe-caused pain can vary in location on the foot, from the metatarsals to the medial arch and heel. It may also be reported at the ankle as the joint moves anteriorly in response to heel height, placing the foot into a plantar-flexed position.
The location of women in the U.S. also has an impact on their shoe choice and dictates the average heel height.
According to a shopping website study, Puerto Rico, Florida, and Nevada women have an affinity toward stilettos or higher-heel heights.2 In addition, they tend to wear shoes that are too small for their feet; a survey on women’s shoes found that women commonly wear shoes that are smaller than needed, and that nearly 75 percent of those surveyed were found to have one or more foot deformities.3
It has also been noted that as the shoe heel is higher, the wearer perceives the foot to be shortened, and this leads to the choice of a smaller shoe size. The literature does support this theory, and also that the shorter the shoe heel, the longer the foot is perceived.4
The higher the heel height, the greater the pressure on the metatarsal region and medial forefoot and impact during foot strike during gait, which can be enhanced if the individual experiences pronation with normal gait. This is in addition to the anatomical shortening of the Achilles tendon due to chronic wear of excessively high heels and improper biomechanics of the foot.5
As heel height increases, it is common on a postural analysis to note that the knees tend to become hyperextended and this results in an associated hyperlordosis of the lumbar spine. As the lordosis increases, the pelvis should be analyzed for anterior pelvic tilt. It has also been noted that younger females tend to have greater impact on the lumbar lordosis from heels than older females.
It is well-known that women are more likely to seek chiropractic treatment, and their age range tends to be younger than that of men.6 As this trend continues, and as women continue to wear shoes with high heel height, you have the opportunity to add an educational component to your patient care.
The impact of footwear on the closed kinetic chain and the pelvis and lumbar spine of the patient has been discussed for years; however, this is even more significant now given the fashion of higher heels.
It has also been noted that women are more likely to care for their feet than men are, so how can you help educate them about fashionable footwear and the impact it has on the body? Here are a few tips to share with patients:
- Choose a shoe with a wide toe box and avoid pointy-toed shoes. The wide toe box creates more room for toes.
- Choose shoes that have a heel height of 1 inch or less. Kitten heels are a good option, as they are fashionable and do not have as great of an impact on the arch of the foot.
- Consider heels that have support already within them, such as extra support under the metatarsal region, where most of the pressure occurs.
- Consider dress-shoe orthotics to assist with normal biomechanical function as well as decreasing foot pain in heels up to 2 inches.
- Be cautious of platforms and wedges as there is a greater likelihood of injury when wearing them as they affect balance.
- Remind your patients not to wear heels every day and to take a break.
The average American takes about 5,120 steps a day. Most people will walk thousands of miles over a lifetime. With each step, improper footwear can cause degenerative changes in the muscles, joints, and connective tissues of the feet, which have implications all the way up the kinetic chain.
Whether it’s switching out those stilettos for a lower heel with added orthotic support—or better yet, retiring their heels completely—stress to your patients the importance of proper pedal support.
Kristina (Kris) L. Petrocco-Napuli, DC, MS, is currently an associate professor at National University of Health Sciences-Florida. She is a graduate of New York Chiropractic College, and also received her master’s degree in instructional design development and evaluation from Syracuse University. She is frequently sought after as a national speaker and has a strong interest in clinical and educational research. Petrocco-Napuli can be contacted at firstname.lastname@example.org or on Twitter @drkrispn.
1 American Podiatric Medical Association. “Today’s Podiatrist Survey 2014. Public Opinion Research on Foot Health and Care Findings from a Survey of 1000 US Adults.” http://www.apma.org/files/APMA2014TodaysPo diatristSurveyAllFindings.pdf. Published March 2014. Accessed Dec. 2015.
2 Gilt Tech. “Stilettos by State: A Gilt Infographic While. http://tech.gilt.com/2014/10/29/stilettos- by-state-a-gilt-infographic-while. Published Oct. 2014. Accessed Oct. 2016.
3 Frey C, Thompson F, Smith J, Sanders M, Hortsman H. American Orthopedic Foot and Ankle Society Women’s Shoe Survey. Foot Ankle. 1993;14(2):78-81.
4 Cowley E, Chevalier T, Chockalingam N. The Effect of Heel Height on Gait and Posture: A Review of the Literature. J Am Podiatr Med Assoc. 2009;99(6):512-8.
5 Esenyel M, Walsh K, Walden J, Gitter A. Kinetics of High-Heeled Gait. J Am Podiatr Med Assoc. 2003;93(1).
6 Weeks W, Goertz C, Meeker W, Marchiori D. Public Perceptions of Doctors of Chiropractic: Results of a National Survey and Examination of Variation According to Respondents’ Likelihood to Use Chiropractic, Experience With Chiropractic, and Chiropractic Supply in Local Health Care Markets. J Manipulative Physiol Ther. 2015 Oct;38(8):533-44. doi: 10.1016/j.jmpt.2015.08.001.