Foot Pain: High Heels and Injury

I was watching Jurassic World the other day with Bryce Dallas Howard running jurassicworldposterheelsfrom velociraptors and all I could think was- is this where she rolls an ankle?  Tottering on her high heels she manages to dodge all manner of Tyrannosaurs, Hadrosaurs and Allosaurs.  So it got me thinking, are high heels not that bad for sporting endeavours or are we doomed to spend our lives correcting foot deformities (apologies to Carrie Bradshaw)?

A fine example of foot injury is seen in the IT Crowd episode “Calamity Jen”

Three possible pathological entities have been linked to high heel use – hallux vagus, mechanical injury and osteoarthritis. Of these hallux valgus or bunion creation is the most common.  This is thought to occur when the forefoot is squeezed into the very small toe of a hight heel or of a misfitting shoe and causes a deformity of the great toe.  This  sees the first digit (big toe) bent towards the little toes permanently forming a bunion.  When this happens the patient experiences an increase in pain when walking, when using shoes and when moving the toe.

Four studies have assessed the association between high heels and hallux valgus. Three out of these four studies found a link between the use of high heels and development of bunions.  The good news for high heel lovers is that despite this link the quality of the studies wasn’t fantastic so even in the face of these results you may still choose to risk style over comfort.

Various mechanical injuries can occur during “high heel misadventure” i.e. falling over.  Injuries include fracture of the forearm, pelvis, lower leg, and feet due to clumsiness associated with high heel use.  In addition there is an increased falls risk seen in the elderly and an increased risk of multiple falls in patients of all ages when wearing high heeled shoes.  One epidemiological study found that up to three quarters of stair injuries in working women under the age of twenty-four were due to use of high heeled shoes.  When looking at factors that contributed to these injuries heel height was the main significant factor seen to increase the risk and severity of injury.  So higher the heel, more likely you are to break an arm.

Less obvious in the disaster scenes of Jurassic World is the fact that Bryce Dallas Howard may have been inadvertently increasing the wear and tear on her knee cartilage by wearing heels whilst trying to outrun a tyrannosaurus.  Knee osteoarthritis has been observed to be more common in women than men and one of the few differences between men and women is the popularity of the use of high heel shoes.  This is unique to modern times as, according to Wikipedia, the first high heel shoes were originally made for men in the 17th century and allowed riders to be able to sit in the stirrup on their horses more easily.  Now I’m no historian, especially when it comes to the bygone era of brogues, but I assume that this would mean that the wearing of heels became associated with horses and wealth thus becoming a desired form of status- check these out.  As Ottoman forces and Europe started to have increased interactions, these shoes transferred into the European Royal Courts, such as the court of Louis XIV.  Heels worn by women and men started to change around the end of the 17th century with male heals widening and female heels narrowing.    The link between high heels and female sexuality is thought to have been connected to pinup girl posters in World War II completing the popularity of the footwear demonstrated today.  But I digress….

So how does this footwear impact the knee? Motion studies have shown that men and women have similar biomechanics when walking barefoot.  When the gait is altered by footwear the biomechanics in heel wearers may cause osteoarthritis of the knee based on the fact that knee arthritis is twice as common in women than men.  How could this be possible?  Manolo Blanik, noted spanish fashion designer, was heard to say that “you put on high heels and you change,” and he is right when it comes to motion through the knee joint. It has been shown that increasing the heel height of a shoe will result in initial increased flexing of the knee, increased straightening of the leg during extension, and increased movement towards the midline of the leg.  Several studies have shown that each of these changes in gait are all by themselves associated with an increase in risk of osteoarthritis in the knee.  However, despite this there have been no studies to date that have established a definitive link between high heel use and osteoarthritis.  Further studies are required (but unlikely to be funded by Mr Blanik I’m sure).

So it has been shown that high heeled shoes have been linked to bunion development, that they have been linked to increased risk of mechanical injuries in wearers and that this risk is particularly significant in women under the age of twenty-four and that high heeled shoes cause a change in stance and gait of their wearers. Individually each gait change is associated with increased risk of osteoarthritis of the knee however the direct link between heels and degenerative knee changes has not yet been definitively established.

Thus footwear is important to not only the health of your feet but can impact your gait and your knees, not to mention contribute to a nasty fracture.  And Jurassic World is a rehash of the first movie- I give it three out of five metatarsals.

GPearls on the GC

  • high heels change the way you walk, causing “an exaggeration of a prototypical feminine gait”.
  • there is increased risk of falls and fracture in those who wear heels
  • Further research is needed to establish the exact risks of wearing heels, although current evidence indicates they may be protective against tyrannosaurs

From Barnish MS, Barnish J.  High-heeled Shoes and Musculoskeletal Injuries: a Narrative Systematic Review.  BMJ Open 2016;6

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