December 2016

Popularity of high heels wanes, but issues remain

Foot health experts say that, overall, women are less enthusiastic about high-heeled shoes and smarter about wearing them in moderation. But those who still feel the need to wear heels in professional or social situations can benefit from clinicians’ advice and, at times, footwear modifications.

By Lori Roniger

Although many women no longer feel compelled to wear high heels for work or socializing, a check of the headlines indicates there are still instances in which women are required or pressured to wear them.

At the 2015 Cannes Film Festival, multiple women—some with medical conditions—were famously turned away from screening events for wearing rhinestone flats rather than heels.1 Cocktail waitresses at Foxwoods Resort Casino in Mashantucket, CT, complied with their employer’s 2-inch heel requirement for decades until their union successfully quashed it in 2013.2 A similar 2015 case in East London, involving a receptionist sent home for failing to wear shoes with a 2- to 4-inch heel, led to union involvement as well as scrutiny of prime minister Theresa May’s well-known fondness for kitten heels.3,4 And in 2013, the US Defense Intelligence Agency—helmed at the time by Lt. Gen. Mike Flynn, president-elect Donald Trump’s choice for national security advisor—included a “no flats” policy among its dress-code requirements for women.5

The good news is foot care experts say that, overall, their patients and the general population have become more savvy in recent years about the risks of high-heeled shoe wear and are prioritizing foot comfort and health more than in the past.

“I think people are becoming smarter about their shoes now­adays,” said Naleen Prasad, DPM, who is in private practice at Bay Area Foot Care in Castro Valley and Dublin, CA. “They are choosing comfort.”

Modifications, including foot orthoses and padding, can help adjust a fashion-forward shoe to better fit a woman’s foot, rather than forcing her foot to adjust to the shoe.

Nevertheless, some women still do prefer to wear heels for work or play—whether they are pressured to do, feel certain styles are more appropriate in the workplace or at formal social events, or simply like the aesthetics of a higher heel. These footwear choices can negatively affect ankle strength and Achilles tendon structure, contribute to the development of bunions and other forefoot deformities, and alter gait mechanics in ways that can increase the risk of knee and hip osteoarthritis (see “High heels: Elevating the discussion,” October 2014, page 16).

Women who come to see foot care practitioners after developing foot pain and problems due to wearing high heels are more likely to be ready to make a change than in the past, practitioners say. But practitioners also know that footwear trends related to heels and other attributes come and go and that, although they say the popularity of high-heeled shoes seems to have receded in recent years, they could come striding back.

That’s one reason why some practitioners avoid banning heels completely, instead advising moderation with regard to heel heights, styles, and time spent wearing them.

“Treat it like dessert,” said Jane Anderson, DPM, who practices at Chapel Hill Foot and Ankle Associates in North Carolina, of the advice she gives her patients.

Style sensibility

Anderson said she sees some professionals, such as lawyers and salespeople, who feel that high-heeled styles are the most appropriate for their work.

“Usually I will try to guide them to find something that is better for their feet,” she said. “There are some options out there and certainly sensible ways to wear high heels.”

Shoes contribute to the problem in many of Anderson’s female patients who consult her about foot pain. They may have conditions such as metatarsalgia, neuromas, or bunions. She spends a lot of time talking to her patients about the kinds of shoes that they wear.

Patients will come into her office in heels, and she advises, as do other foot-care practitioners, that they wear shoes no higher than 2 inches.

“Two inches and lower is the safest way to wear heels,” Anderson said.

She’ll ask her patients to take off their shoes and measure them in her office, and she’s found that many of them believe their heels are shorter than they are.

“People are usually off by an inch,” Anderson said.

Anderson advises patients to look for shoes with soft flexible uppers and a round toe box. A chunkier heel can be more stable than a narrow stiletto type, she said. For women with ankle instability and high arches who want to wear a heeled or dressy shoe, Prasad recommends a thick strap that wraps around the ankle.

Anderson noted that there are now many European brands and some American ones that are well made, good for feet, look polished, and come in a variety of widths and heel heights. Many are available at online stores that offer free returns to help customers find the best fit.

Moderation and modifications

Grace Torres-Hodges, DPM, who practices in Pensacola, FL, also helps women wear heels in ways that are better for their bodies.

“For healthy feet, my constant mantra for women regarding heels is moderation,” she said.

Anderson also recommends wearing heels for only limited periods and alternating heeled shoes with flats. Otherwise, an individual’s musculature can shorten6 and it can become dif­ficult to wear flat shoes. Some of her patients can’t wear athletic shoes because they have worn heels so much.

“It’s important to switch it up,” she said.

Shoe modifications, including foot orthoses, are another trick practitioners use; such ­mod­ifications can help adjust a shoe to better fit a foot, rather than forcing the foot to adjust to a shoe, Torres-Hodges said.

“If a pair of shoes is causing neuroma pain or is exacerbating the bad biomechanics already associated with buni­ons and hammertoes, many times a modification in the shoe can be made directly or an orthotic can be used to hold the foot in a different position,” she said.

If a patient with meta­tarsal pain brings in a heeled shoe to wear at a special event, Prasad may place padding in the shoe. She thinks women are being smarter about how they’re wearing heeled shoes, like taking them off to dance at a wedding rather than wearing them all night.

“It’s not like you can’t wear those high heels,” she said. “You can be smart about it.”

Likewise, Torres-Hodges said, there are some people who like to wear heels socially regardless of the pain or physical problems they cause. And, if a bride, say, has a shoe that she absolutely wants to wear, Torres-Hodges will adjust it to the patient with padding or orthoses. In some cases, a metatarsal pad can help.

But some shoes—those with a 3- to 5-inch heel, for example—simply won’t make the cut.

“My advice would be that it’s not the best designed shoe for them,” Torres-Hodges said.

And there are also times when Torres-Hodges will recommend a patient take a break from heels altogether.

“When a patient comes in for treatment, it is usually the result of pain,” Torres-Hodges said. “If the shoes that they wear at work, such as heels, are causing their problem, I am quite frank with them that, in order to heal, they would have to discontinue wearing them for either a period of time or for good. My priority is protecting the health of the foot.”

Platform strategies

Prasad recommends platform-type heels or boots with a little wedge and said they can work well for women who want or are required to dress up.

“I am not against heels completely because there are certain high heels that will work,” she said.

She explained that the ratio of heel height to platform height is key. So, if a shoe has a 1-inch platform and 3-inch heel, it will balance out to a heel elevation of 2 inches.

“There are many brands that make very good heels,” she said.

Torres-Hodges will also recommend platform styles for patients who feel the need to wear heels.

“Perhaps because I live in a beach community, I have not had an instance where a patient was required to wear high heels and not given options or an opportunity for modifications,” she said. “However, if their job encourages them to have a specific look, I try to work with their requirement to look for a platform shoe rather than a steep angle in a high heel.”

With her patients who prefer to wear heels, Prasad likes to look at the shoes herself.

“I ask them to bring their dressy shoes to me so we can decide what will work and not work,” she said.

Prasad recommends examining the angle of the heel of a shoe, noting that, in her clinical experience, a heel that is oriented perpendicular to the floor can contribute to back pain.

“If the heel is pointed straight up and down, it’s not going to be comfortable,” she said. “We all have back issues. It really puts pressure on our backs.”

She said that a block heel that is angled forward slightly and gradually tapered at the bottom will work better.

“Those shoes are much more comfortable,” she said.

The opposite extreme

Prasad said she doesn’t see high heels as the biggest type of shoe problem in women.

“I’m not as against heels as [I am] against ballet flats,” she said, referring to the type of flat shoes that lack arch support, which can affect biomechanics.

Torres-Hodges agreed that wearing flats, including flip-flops, can also be a problem.

“If you go to extremes with high heels or flats, you’re begging for some issues to occur,” she said.

While helping women find better footwear or at least modifying existing problematic shoes can prevent or improve foot problems in women, some practitioners also recommend exercises. Torres-Hodges suggests stretching and conditioning ankle exercises to all her patients.

“Because heels shorten the Achilles tendon, any exercise that stretches it is helpful,” she said. “This can include static dorsiflexion at the ankle. Toes raises and dips allow contraction and lengthening of the tendon. The medial and lateral aspects of the ankle joints can also use conditioning. Some exercises include drawing the alphabet with your foot, ankle circles clockwise and counterclockwise, and using a wobble board.”

Choosing comfort

Overall, practitioners said the number of patients wearing heels and coming in with problems related to them has been waning.

“We’ve harped on it for a long time,” Torres-Hodges said.

While in the 1990s, women in New York City and other urban areas were just starting to commute in athletic shoes and keep dressier shoes in the office to wear during the day, practitioners said some of their patients now will slip on their heels just for business meetings.

Torres-Hodges said the lawyers and bankers among her patients do wear sensible shoes.

“That’s the one part where they’ll compromise,” she said regarding what they wear.

Girls have now grown up with an emphasis on the importance of healthy feet and comfort and without the stereotype that women must regularly wear heels.

She said that girls have now grown up having the importance of healthy feet and comfort emphasized and without the stereotype that women must wear heels. Around five or six years ago, she said, she was seeing tweens wearing higher heels, but that trend has abated.

Prasad, who sees many pediatric female patients, agreed, noting that a few years ago, girls were also wearing flat sneaker-type shoes that didn’t have a lot of support.

“They are choosing comfort these days,” she said.

Torres-Hodges noted she will push her recommendation for proper footwear harder in tween and teen patients than in adults. Wearing platform shoes or heels at that age may not allow the foot to develop properly and can have other negative effects,7 she said.

I was pleased when my 10-year-old daughter said recently that heels should be worn only occasionally, for special events. She has, after all, grown up with a mom who writes about biomechanical issues and rarely wears heels these days.

But might the high-heeled footwear choices of prominent women, such as British royal Kate Middleton or Donald Trump’s daughter Ivanka, influence future fashion trends? Torres-Hodges doesn’t think so.

“I don’t predict it in my neck of the woods,” she said.

Lori Roniger is a freelance writer based in San Francisco.

  1. Wiseman A. Cannes: Women denied Palais entry for wearing flats. ScreenDaily website. Published may 19, 2015. Accessed December 7, 2016.
  2. Sole survivors: Foxwoods casino cocktail waitresses fight high-heel rules. Fox News website. Published June 10, 2013. Accessed December 7, 2016.
  3. Receptionist sent home from PwC for not wearing high heels. The Guardian website. Published May 11, 2016. Accessed December 7, 2016.
  4. Ditch high heels to promote equality at work, Theresa May told. The Guardian website. Published September 13, 2016. Accessed December 7, 2016.
  5. Zavadski K. Gen. Mike Flynn’s office told women to wear makeup, heels, and skirts. The Daily Beast website. Published November 18, 2016. Accessed December 8, 2016.
  6. Csapo R, Maganaris CN, Seynnes OR, Narici MV. On muscle, tendon and high heels. J Exp Biol 2010;213(Pt 15):2582-2588.
  7. Silva AM, de Siquiera GR, da Silva GA. Implications of high heeled shoes on the body posture of adolescents. Rev Paul Pediatr 2013;31(2):265-271.

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