‘High Heels Challenged!’
Welcome to ‘challenging high heels’.
In researching the subject it would appear recent interest in high heels is waning. Is there a case for banning high hells? Material that exists on the subject appears to stretch back to the late 20thcentury and first decade of the 21st. Newspaper reports form the main bulk together of opinion from journalists, mostly female, but not entirely. There is no shortage of evidence which is written from every standpoint. In the second of my article on high heels I want to look a little more at the science. That said I prefer to keep it simple.
The case for safety
The TUC and Health safety executive, both UK organisations have published guidelines on footwear safety. Perhaps more than anything, safety lies at the top of the list of concerns by podiatrists committed to good foot health. Researchers at Aberdeen University carried out a review of scientific studies into shoes. Data revealed that while high heels increased women’s attractiveness to men, studies also showed that injury and conditions associated with the body’s muscles, joints and bones were at risk. Collectively these are called musculoskeletal conditions. Researchers contrasted the response of the UK Government with that of the Canadian province of British Columbia, which had previously changed the law to ban employers from requiring female staff to wear high heels. Our mind goes back to Nicola Thorpe, where I had discussed her fate in Part 1 when she was forced to wear high heels by her bosses at Portico in 2017.
Max Barnish, at Aberdeen University, considered that despite the huge amount of evidence against heels, complex social and cultural reasons competed with risks. Heather Morgan, a lecturer at the same university believed that the message was not trying to tell people not to wear high heels but to provide information so those users made judgements based on the health risks with social benefits. The lawmakers need to change the legislation, in the UK, while in Canada this has clearly already happened. No-one in the workplace or in a licensed public social venue should be made to wear such footwear.
Real data
In Australia between 2006-10, Williams & Haines (2014) reported that 240 injuries had been recorded in a Victoria emergency department where 98% were women and younger than 55 years. Injuries occurred mostly on Sundays between 8am-12pm in 1/3 of cases. The winter season had a greater incidence and the ankle was the most common site. Research between 2002 and 2012 at the University of Alabama showed results from high-heeled-shoe findings which mirrored the injuries in the Australian study, again taken from a hospital emergency department. McGwin in the Alabama paper (Journal of Foot and Ankle Injuries) was cited by Shepard pointing again to younger people suffering.
People between the ages of 20 and 29 were most likely to suffer an injury, followed by the 30-39 age group. Bob Shepard 2015
While we can use reports from newspaper incidences as case histories, and why not, this is evidence, it is always useful to look at the academic side of the subject. Put simply this means ethically approved with controlled studies.
Posture and feet
The spine shape changes as the hip is influenced by heels, and some might argue this makes the feminine outline more attractive as the buttocks are accentuated. Lewis et al (2017) pointed out that the lumbar spine forms a greater curve. The picture is taken from Lewis 2017 (Frontiers in Psychology accessed from the internet 7/8/19). The author has drawn lines to show the curvature change and centre of gravity line (CoG). If the body’s CoG moves forward, the muscles of the back have to work harder, and this causes the lower curve (lumbar) to become accentuated. Depending upon the heel height the CoG will alter through the foot. If weight is distributed crudely at 50:50 although Broega (2017) 43% on the ball of the foot and 57% under the hindfoot, the elevated heel increases the forefoot pressure above half that pressure as the heel rises. Women’s attraction to high heels has evolved over time and a research project used 82 men to study photographs of female attractiveness. Lewis and co-workers (2017) looked at the evolution of high heels, the effect on the spine and attractiveness toward certain shoe designs in this study.
In 2010 Blanchette and co-workers published an academic paper in ‘Gait & Posture’, a formal scientific journal. The study used 15 healthy women who wore high heels. Three heel heights were used and the forces measured. These included the downward or vertical force from gravity. However, they were interested in the forces that run parallel to the sole of the foot and the potential for causing changes due to friction.
As the heel height increased the vertical forces dropped by 12%, but the frictional shear forces increased by the same amount. As our centre of mass moves forward so does the line of gravity. Hip and knee flexion increases. In other words, there was a trade-off in position for a shift in forces. We need a certain amount of friction to push our foot forwards but in the wrong place, added to an unstable heel, that friction works against our human frame which is less stable than a four-legged animal. That centre of mass is easy to push outside the imaginary white line, and when that happens you fall. The only safeguard is a walking stick or crutch!
Height effect on the foot
The effect the foot, ankle, and musculoskeletal design causes ankle muscle movement to reduce. The step length, the total range of ankle movement and balance control are all altered. The strain on the muscles and tendons of the lower leg can lead to musculoskeletal disorders later in life. While most of the injuries affected the ankle or foot, nearly 20 percent involved the knee, trunk, shoulder, or head and neck. More than half were strains or sprains, with fractures accounting for 19 percent of all injuries. McGwin’s (with other authors) study noted that nearly half the injuries occurred in the home, whereas Williams & Haines found that 19.2%, accounting for most injuries in the study, arose in unspecified places.
From a podiatrist’s viewpoint, the extension of the toes alone exposes the ball of the foot to greater damage as the fat pad moves forward and any existing hammertoe deformity adds to pressure problems. The additional forefoot pressure may not directly cause a foot condition, but it will accentuate problems causing callus, corns, and deeper tissue damage like nerve impingement (Morton’s neuroma) and fluid sacs called bursa. Cutmore, a podiatrist from New South Wales, advised that the achilles tendon could be slowly destroyed as the tendon is shortened, which again would throw the body out of balance and strain the knee. The word destroyed is rather emotive but then falling can equally be destructive as the ankle mechanics alter and sprains are well reported from accident department statistics. But it is not just a matter of the height of the heel. We need to consider the surface area and that comes back to the stiletto heel.
Surface area
We must draw attention to the surface area of the base of the heel. Something the size of a drawing pin creates far more instability than a wider platform. Elton John led the fashion amongst others for men in the 1970’s with shoes called stacks. The heels and soles were built up and it was the answer to the shorter man’s concerns for height. These soles while having plenty of area were stable in comparison to the ‘stiletto’ design, but nonetheless they were condemned as being unstable. And so we need to be specific about what we are challenging. Design or safety? The TUC has a close relationship with the College of Podiatry in regard to employment and we find their influence in the guidance on footwear at work (Working feet and footwear – www.tuc.org.uk/sites/default/files/footwear.pdf)
As McDonnell says,
concern about the potential impact of wearing high heels on women’s health, and in causing musculoskeletal and long-term foot disorders, have been expressed in medical circles for more than 50 years. Some organisations have called for compulsory wearing of high heels at work to be outlawed.
In 2009, the Society of Chiropodists and Podiatrists (UK) (now the College of Podiatry) made the statement that –
‘Women workers should not be made to adhere to a dress code that can damage their feet and should have the choice to wear footwear that will not leave them prone to long term foot health problems.’
It is unlikely that we will see a change in the availability of shoe designs that lead to injury, and in a world of consumerism, it is for the individual to determine what is right as evidence is not sufficient to condemn shoes. It takes a newspaper event that raises questions in Parliament to tease out the issue of high heels. However, the popularity of heels seems to be on the decline as females prefer flat shoes in some 66% of cases compared to just over 10 percent who prefer to wear high-heeled shoes.
Surgery, the big toe and high heels
Angela, my patient in Part 1 was driven by the look of her fancy red shoes. First the look of the shoe, and secondly because it made her feel good. However, her sizable bunions on both feet were going to be compressed unless I could help her. As a former podiatric foot surgeon, my role was not to undertake surgery so that she could use high heels afterward, but that was a risk I would have to take. I have seen a few patients return after surgery and feel bitterly disappointed to find high heels were not ideal. This is worse when the big toe is surgically stiffened. The effect of surgery should be discussed clearly before the event.
Women should have the last word
It has been suggested that a smaller calf muscle size is achieved by a high heel, which is true. Shapely legs have been the cause of many male catcalls from the heights of scaffolding if we believe the films and adverts of the past. I came across a blog from Augusta McLaughlin on the matter of legs;
Here’s a little secret I wish every woman knew: Our legs don’t need to be elongated, clenched or upheld at a particular angle to be beautiful and embraceable. I’ve thought a lot about this fact since last May when I decided to stop wearing high heels for a year. Variety
McLaughlin (2015,2016) again,
I’ve also learned that high heels cause a whole lot more than a bit of temporary pain. Women should have every right to wear whatever shoes they wish, without judgment…I find it interesting that virtually no articles on high heel risks suggest giving them up as a viable option, much less the one sure way to prevent or minimize these problems.
McLaughlin’s female-driven blogs carry material that is hard to ignore, partly because it has been derived from professional sources. The risks from high heel shoes are emphasised in her article (click here) if you want a list and more information from a predominantly female perspective. As I have never worn the style of shoes women use I am unable to judge the effects, but I know from a scientific point of view that mechanics change with postural shifts created by raising the arch.
Footwear is a personal choice and better scientific study from epidemiological information – on both health effects and on risks to safety from high heel wearing – might actually help women themselves to have more confidence in the shoe choices they make for the workplace.
The key to common sense can be summarised
- Wear the right footwear for the right occasion and setting.
- Reduce the time of exposure and limit the time allocated to wearing heels
- Carry a spare pair of shoes with lower heels for comfort, especially when driving
- Examine heels for damage and fractures before wearing them each time
- Protect skin and bumps from pressure
- Use a small forefoot pad to reduce frictional forces on the forefoot available from pharmacists
- Avoid running in high heel shoes. Use the right footwear for the right job
Thanks for reading ‘High Heels Challenged’ by David R Tollafield
Original published 12th August 2019 and modified 20 March 2021
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