Well-Heeled Now, Hobbled Later


Doctors have determined that high heels can be hazardous to your health.

For several years, foot surgeons have been warning women that wearing shoes with high heels and narrow toes can lead to painful and often-permanent foot deformities. Now, a study has found the first evidence that high-heeled shoes may also contribute to knee arthritis in women.

Meanwhile, a group of surgeons took their pro-foot campaign a step further, announcing results of extensive tests of comfort, fit and flexibility that were performed on 11 shoe styles they found to be the most popular among working women.

The group, the American Orthopaedic Foot and Ankle Society, awarded a seal of approval, similar to the American Dental Assn. seal that often appears on tubes of toothpaste, to four styles that passed all the tests. They're not revealing which shoes failed.

"We're not trying to identify bad shoes," said Cherise Dyal, an assistant professor of orthopedic surgery at New York's Albert Einstein College of Medicine. "Our goal is to educate women on how to buy shoes appropriately . . . to prevent problems and pain."

For many women, painful and misshapen feet are the ultimate cost of a long-term love affair with high-heeled shoes. In the United States, women visit orthopedic surgeons for foot problems four times as often as men, and they undergo about 87% of operations performed to correct acquired foot deformities, such as bunions and hammer toes. In societies where people go barefoot or wear flat sandals, acquired foot deformities in adults are rare, and their frequency is the same in both sexes.

The deformities that often develop after years of wearing high-fashion pumps are similar to foot problems that had been seen in Chinese women whose feet were bound by their parents, said Michael J. Coughlin, a clinical professor of orthopedics at Oregon Health Sciences University who practices in Boise, Idaho.

When the feet of such Chinese women were X-rayed, "the deformities were not in the bones at all. They're just in the joint," Coughlin said. "Women of today . . . are achieving the same thing. They're causing these joint deformities by binding their feet in constricting footwear."


Problems tend to develop in the front half of the foot (the forefoot) and include bunions, hammertoes or claw toes, and bunionettes, conditions common in middle-aged and older women that often require corrective surgery.

A bunion is a bump or enlargement on the inner side of the foot, at the base of the big toe. A bunionette is a similar enlargement on the outer side, at the base of the smallest toe. Hammertoes and claw toes are deformities in which the toe curls and its joints protrude upward, often rubbing against a shoe and causing painful corns.

Foot structure, heredity and the elasticity of ligaments can predispose some people to such deformities. But narrow, pointed shoes and high heels also contribute, by compressing the toes and increasing force on the forefoot during standing and walking. With a 3 1/4-inch heel, pressure on the forefoot is more than seven times greater than with a flat shoe.

Coughlin analyzed 3,000 surgeries for forefoot deformities performed in his Boise practice during a 15-year period and found that 87% were done on women's feet. Women had 94% of the bunion surgeries, 90% of bunionette surgeries, 81% of hammertoe surgeries, and 89% of surgeries for neuromas, a painful thickening of a nerve that runs between two toes.

Surgery can improve such foot deformities but usually can't restore the foot completely to normal, said Michael W. Bowman, a foot and ankle surgeon who is chairman of the AOFAS Orthosis and Footwear Committee. "I tell patients up front, 'You can't expect to have surgery and go back and wear this type of shoe,' " he said.

In addition to choosing unhealthy shoe styles, women frequently buy shoes that are too narrow for their feet, according to a 1993 survey by the AOFAS.

Of 356 women who responded to the survey and had their feet measured, 88% were wearing shoes that were too narrow, by an average of one-half inch. Most women's feet are between 3 1/4 inches and 3 3/4 inches wide, Coughlin said, but fashion shoes are usually only 3 inches wide.


New evidence, published in May in the British medical journal the Lancet, suggests that high heels are also bad for women's knees. D. Casey Kerrigan, an assistant professor at Harvard Medical School who specializes in physical medicine and rehabilitation, used special laboratory equipment to analyze the forces that were generated in the knees of 20 healthy women while walking in high-heeled shoes. The research subjects, whose average age was 35, habitually wore high heels.

Kerrigan found that rotational forces compressing the inner part of the knee joint were 23% higher when the women walked in high heels than when they walked barefoot. High heels also prolonged the strain and pressure on the smaller joint between the kneecap and the underlying thigh bone, the patellofemoral joint. Both joints are common sites of osteoarthritis in women.

No one had previously suggested that high-heeled shoes might contribute to knee arthritis. "This is a completely new direction," said Kerrigan. She said the shoes prevent the ankle from working as it should to absorb part of the force of walking, so she suspected they might result in abnormal rotational forces on the knee joint. Walking in high heels tends to rotate a woman's knees outward into a more bowlegged position.

Kerrigan said forces of the magnitude measured in her study have been shown to cause arthritis in rats. She added that high heels also make older women less stable and contribute to falls. "I'm telling anybody who has knee arthritis, 'Just don't wear them!' "


How should women choose shoe styles that are best for their feet?

The AOFAS provides advice for consumers on shoe fit and runs a training program for shoe salespeople, but the society's surgeons worried that they weren't getting their message across. So, a few years ago, the group came up with the idea of testing shoes for desirable qualities and awarding some styles a seal of approval that might help guide consumers. A respected European firm, widely consulted by the shoe industry, would perform the tests. The AOFAS asked shoe companies to submit their products and to pay the cost of testing, about $1,500 for each style tested.

"We didn't have as enthusiastic a response as we would have liked," recalled San Francisco foot surgeon Glenn B. Pfeffer. "Nobody seemed to submit their shoes very much."

Two Rockport shoes, the Mirabel pump and the Somerdale casual shoe, were awarded the seal in 1996. No other companies came forward with shoes for testing. So this year, the AOFAS surveyed 499 American working women about the shoe styles they wore to work, chose the 11 most popular and had them tested.

The tests evaluated such factors as toe shape, heel configuration, slip resistance, cushioning, breathability, flexibility and heel shock absorption, Bowman said. Professional shoe-testers with standard-size feet also wore the styles while walking on treadmills and provided a "comfort index."

Four models, representing a range of styles and prices, passed with flying colors. They were the Easy Spirit "Casual Cypress" flat, retailing for $60; the Enzo Angiolini "Disso" pump, which has a 1 4/5-inch heel and sells for $85; the Reebok "Gusto DMX" athletic shoe, retailing for $70; and the Payless ShoeSource "Sculp," a pump with a 1 3/5-inch heel that sells for just $10.

Bowman said awarding the AOFAS seal of approval to these styles doesn't mean other shoes couldn't also qualify. "This is in no way an attempt to say, 'These are the only good shoes in America,' " he said.

Nevertheless, a shoe industry representative criticized the program as unfair.

"The whole thing is a farce," said Dick Jacobson, president of the Fashion Footwear Assn. of New York. "Those shoes aren't anymore healthy than anybody else's."

Jacobson said the shoe industry has worked hard during the past decade to create new shoe designs and comfort features. "We don't need these guys to tell us what to do," he said. "We have studied all the problems of shoemaking much more than they have."

He said women are smart enough to choose comfortable footwear. "A woman who is going to be on her feet all day should not wear big high heels and tight-fitting shoes," he said. "Every intelligent woman knows that."

Bowman and other foot specialists contended that many women still feel compelled to wear high heels because they think it's expected at certain jobs or social events, or because they're fashion-conscious.

"The fashion industry spends millions of dollars convincing American women that unless they wear a high-heeled shoe shaped like an ice-cream cone, somehow they are not fashionable," Bowman said.

Coughlin said many women also want their feet to appear smaller and their legs longer. "Some people say the reason they [wear them] is it makes a woman walk in sort of an unstable, mincing gait that makes them look . . . a little more vulnerable," he said. "I think there are a lot of sexual overtones in this that, truly, I don't understand."


High-heeled shoes were invented during the Renaissance, and at various periods in history they have been fashionable for both sexes. During the 20th century, however, they've been worn almost exclusively by women.

Surveys by the AOFAS suggest their popularity is on the wane. This year, the society questioned 499 women between the ages of 20 and 50 about what shoes they wore to work. Participants were selected at random. They had to be employed full time in a job that did not require them to wear standardized shoes, but they had to answer yes to the question, "Do you have the perception that there is a dress code where you work, either written or unwritten?"

The participants held a variety of jobs, ranging from bankers, lawyers and engineers to salesclerks, factory workers and secretaries. Sixty-nine percent said they wore flat shoes to work, including 23% who wore athletic shoes. Only 3% wore shoes with heels higher than 2 1/4 inches. No job category contained a disproportionate number of women who wore high heels, Dyal said.

When the society performed a similar survey in 1990, 49% of women reported wearing flat shoes to work (including 14% who wore athletic shoes) and 37% said they wore high-heeled shoes.

Younger women appear to be much more likely to choose shoes for comfort. In this year's survey, 30% of the women ages 20 to 30 wore athletic shoes to work, and none wore high heels. Among women between 41 and 50 years old, 21% wore athletic shoes and 3% wore high-heeled shoes.

If that trend continues, it is likely that during the next couple of decades, the number of women in their 40s, 50s and 60s having foot surgery will go down, said Coughlin.

"I can have the pleasure of seeing my daughters and their daughters have good feet and not have surgery," he said. "That will make me happy, because I'll have done something for women."

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