When Good Women Wear Bad Shoes
What’s a Pedorthist to Do?

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What’s a Pedorthist to Do?

Many women—celebrities, lawyers, businesswomen, homemakers, teenagers, grandmothers, and everyone in between—are passionate about their footwear. Former Philippines First Lady Imelda Marcos owned about 3,000 pairs of shoes; singer Celine Dion has been quoted as saying she owns between 2,000-3,000 pairs. Women's shoes can push the very boundaries of luxury. For example, Harry Winston designed a spectacular pair of red slippers to celebrate the 50th anniversary of the classic movie, The Wizard of Oz. Priced at $3 million, they are considered to be the world's most expensive shoes. Although Dorothy's shoes sparkled with sequins, the Winston creation glows with 4,600 rubies weighing 1,350 carats, plus diamonds totaling 50 carats.

Although not quite on the same scale, the average American woman owns 19 pairs of shoes, and the average British woman will spend about £16,000 (about $25,000) for shoes during her lifetime, according to surveys. (Author's note: UK figures are from gocompare.com, U.S. figures are from ShopSmart magazine.)

Although women love their shoes, sadly, those shoes don't always love them back. Almost half (43 percent) of U.S. women report at least modest injuries as a result of the shoes they wore, according to a 2007 survey conducted by the Consumer Reports National Research Center. Eight percent reported serious injuries including sprains and breaks.

Not surprisingly, those sleek, gorgeous high heels, especially those with narrow, pointed toe boxes, are a prime cause of foot problems. As pedorthists and other foot-care health professionals know only too well, wearing high heels regularly for lengthy periods of time can lead to a host of ills, including hallux valgus, bunionettes, hammertoes, and Morton's neuroma. And that's not all.

The Height of Trouble

High heels can also cause foot and back pain by altering the wearer's center of gravity. When the heel is raised, the body's positioning is thrown off balance, which can cause the spine to curve abnormally in an effort to maintain balance, according to www.spineuniversity.com, an online resource for spine information and related health issues.

Those to-die-for high heels can lead to knee osteoarthritis and joint degeneration, according to research by master's student Danielle Barkema, a kinesiology student at Iowa State University, Ames. "Obviously with research like this, you can't say with any certainty that if you wear high heels regularly you will develop osteoarthritis," Barkema was quoted as saying by ScienceDaily (August 2, 2010: www.sciencedaily.com/releases/2010/08/100802141901.htm). "There are probably...[high-heels wearers] who do and those who do not. However, based on this information, wearing high heels puts individuals at greater risk for developing osteoarthritis. And it seems to be that the higher the heel height, the greater the risk."

Barkema also found that wearing heels—especially those two inches and higher—can strain the lower back, since the shoes alter body posture by changing joint positions at the ankle, knee, hip, and trunk. Barkema was assisted in her study by Philip Martin, PhD, Iowa State Department of Kinesiology chair.

Surprisingly, some women who regularly wear high heels suffer discomfort when they switch to flat shoes. Marco Narici, PhD, of the Institute for Biomedical Research into Human Movement, Manchester Metropolitan University, UK, and colleagues decided to try to find the cause of this mystery. Since the muscles shorten if a limb is held in a shortened position over an extended period of time, they thought that this might be the answer, according to ScienceDaily (July 16, 2010: www.sciencedaily.com/releases/2010/07/100715194407.htm).

However, calf muscles of women who wear high-heel shoes were the same length as those of the women who generally wore flats. Further research, though, revealed that the calf muscle fibers were 13 percent shorter and that the high-heels wearers' tendons were much thicker and stiffer than those of the flat-shoes wearers. Narici and his team realized that by thickening and stiffening, the Achilles' tendon compensates for the shortened muscle fibers in the calf muscle, allowing wearers' calf muscles to function optimally as they walk. However, this causes discomfort when walking on flat feet because the tendon cannot stretch adequately. The full text of the research article by Narici and colleagues was published online July 16 in the Journal of Experimental Biology (Csapo, R, Maganaris, CN, Seynnes, OR, and Narici, MV. "On Muscle, Tendon and High Heels," Journal of Experimental Biology, 2010; 213:2582-2588).

Flip-Flops: Downside, Upside

At the opposite end of shoe design, those oh-so-comfortable flip-flops can cause some not-so-comfortable foot problems.

Researchers at Auburn University, Alabama, found that wearing thong-style flip-flops can result in sore feet, ankles, and legs. The research team was led by biomechanics doctoral student Justin Shroyer, under the direction of Wendi Weimar, PhD, associate professor, Department of Health & Human Performance and director, Sport Biomechanics Laboratory.

"We found that when people walk in flip-flops, they alter their gait, which can result in problems and pain from the foot up into the hips and lower back," Shroyer was quoted as saying in an Auburn University press release (http://education.auburn.edu/news/2008/june/flipflop.html). "Variations like this at the foot can result in changes up the kinetic chain, which in this case can extend upward in the wearer's body."

Both Shroyer and Barkema presented some of their findings at the 55th Annual Meeting of the American College of Sports Medicine (ASCM) in Indianapolis, Indiana, May 2008.

Surprisingly, those much-loved flip-flops and other flat, flexible footwear have an upside: they can help protect knees from osteoarthritis, according to research by Najia Shakoor, MD, and colleagues. Shakoor is an associate professor in the Department of Internal Medicine at Rush Medical College and serves as an attending physician at Rush University Medical Center in Chicago, Illinois.

The researchers analyzed the gait of 31 patients with osteoarthritis symptoms in the Rush Motion Analysis Laboratory while they walked barefoot and again while wearing four popular shoe types: Dansko clogs, which are often worn by healthcare professionals who have to be on their feet much of the day; Brooks Addiction™ stability shoes, which are prescribed for foot comfort and stability; Puma H-Street shoes, a flat athletic shoe with flexible soles; and flip-flops, according to a news release from Rush University (www.rush.edu/webapps/MEDREL/servlet/NewsRelease?id=1366).

The loads on the knee joint were up to 15 percent greater with clogs and stability shoes compared with flat walking shoes, flip-flops, and barefoot walking. "Currently, knee braces and wedged orthotic shoe inserts are used to relieve the load on the knee joints of patients with osteoarthritis, but everyday footwear is also a factor to consider," Shakoor says. "The results in our study demonstrate that the reduction in load achieved with different footwear, from 11 to 15 percent, is certainly comparable to reduction in load with braces and shoe inserts."

Several footwear factors affect joint loading, Shakoor says. "Heel height is one factor and may explain why the stability shoes and clogs in our study, both of which had higher heels, produced greater knee loads. Stiffness is also a factor. Clogs and stability shoes, conventionally believed to provide appropriate cushioning and support, actually increased the loading on the knee joints, as opposed to shoes with less 'support,' flatter heels, and more flexibility."

Shakoor cautions, however, that knee loading is not the only consideration in any clinical recommendations based on her study. The study, "Effects of Common Footwear on Joint Loading in Osteoarthritis of the Knee," was published in the July 2010 issue of Arthritis Care & Research (Volume 62, Issue 7, pg. 917-923).

Women's Feet Are Different

Certain foot pathologies affect women more often than men. For instance, women are two to four times more likely to have hallux valgus than men, likely due to a combination of intrinsic structural features and extrinsic footwear options, according to Judith F. Baumhauer, MD, and Kathryn O'Connor, PT, in an article in the September 2010 issue of AAOS Now, published by the American Academy of Orthopaedic Surgeons and the American Association of Orthopaedic Surgeons (www.aaos.org/news/aaosnow/mar08/clinical2.asp). Additionally, the incidence of hammer toe is four to five times more common in women.

A fundamental reason why women suffer more from foot problems is simply that women's feet are different than men's. Research has shown that women's feet are not simply smaller versions of men's feet—they differ in shape, structure, and ligament laxity, among other factors, causing differences in gait and greater ankle plantarflexion and range of motion.

"Under studied differences in foot structure, muscle strength, ligament laxity, and proprioception are all intrinsic factors that can initiate a predisposition for pain and injury in females," Baumhauer and O'Connor point out. "Little attention, however, has been given to intrinsic physical differences in male and female foot structure," the authors add, noting that athletic shoes, for instance, have traditionally been designed as scaled-down versions of men's shoes.

The authors reference a 2001 research study by Roshna E. Wunderlich, PhD, and Peter R. Cavanagh, PhD, which examined lower-limb and foot measurements of approximately 300 men and 500 women in the U.S. Army. The researchers concluded that biologic differences existed between male and female feet and legs, noting significant differences in arch shape, size of the lateral side of the foot, great toe, and ball of the foot (Wunderlich, RE, and Cavanagh, PR, "Gender Differences in Adult Foot Shape: Implications for Shoe Design," Medicine & Science in Sports & Exercise, Vol. 33, No. 4, 2001, pg. 605-611). "Women, for example, had a wider forefoot, shorter arch length, and shorter metatarsals compared to men," Baumhauer and O'Connor note. "This study was among the first to promote incorporating the structural differences between the female and male foot into the design and manufacturing of women's shoes." Differences also involve skeletal, cartilage, foot-length-to-body-height ratios, and gait, according to Baumhauer and O'Connor.

Pedorthists Meet the Challenge

Margiano

Many women are not blind to the impact their footwear choices have on their bodies. For some, the siren song of the stiletto is too intoxicating to resist. So, what's a pedorthist to do? The first step is often simply getting clients into the right-sized footwear.

Studies show that 88 percent of women wear shoes that are too small for their feet, Baumhauer and O'Connor point out. Men often wear wrong-size shoes as well. For instance, Ray Margiano, PhD, founder and CEO of Foot Solutions based in Marietta, Georgia, says about 90 percent of Americans in general are wearing the wrong-sized shoe.

"I would say that more than 80 percent of my patients report when asked that they have not had their foot measured in 'years,'" Roger Marzano, CPO, CPed, Yanke Bionics, Akron, Ohio, adds. "They do not realize the foot lengthens and widens with age."

Marzano

"Many people think they 'know' their shoe size," Séamus Kennedy, BEng (Mech), CPed, president and co-owner of Hersco Ortho Labs, New York, New York, says. Shoe sizing systems and lasts vary from manufacturer to manufacturer, and foot size can change over time with age and weight gain, he explains. "Anytime you buy shoes, bring your orthotics with you," he advises consumers. "Try the new shoes with the orthotic inside. Go up a width, a half size, or a whole size if needed. Always buy shoes based on fit—not on the price, the look, or the size you think you are." He adds, "As we like to say in the profession: Good health starts from the ground up."

"One of the most useful tools I employ when discussing footwear with patients is to trace around the borders of their foot while they are standing, then place their shoe over the tracing to illuminate how little space is afforded for the foot in the shoe, or worse yet, how small their shoes are relative to their foot size," Marzano says. "Pedorthists can help by regularly measuring the patient's foot on a Brannock device even if they are not dispensing shoes—just to educate patients about their foot size."

Kennedy

Kennedy and Margiano also like to use the foot-tracing technique to educate patients. "Frequently, the foot tracing is wider than the shoe!" Kennedy exclaims. "This is an easy and clear way to demonstrate to patients that they are jamming their feet into their shoes. Another trick is to fit someone with a shoe before telling them the size. Ask them how it feels. Often they will like the fit; then you can tell them the size."

Aesthetics versus Therapeutics

If a customer wants a comfortable, foot-healthy shoe that is still fashionable, is a pedorthist's only option to shake his or her head woefully and walk away? Pedorthists are probably the first to admit that consumer demand for effective foot care that doesn't sacrifice fashion and aesthetic appeal poses a real challenge for them, but there are compromises that can be made.

"There is quite a steady demand for custom foot orthotics for patients who want to wear fashionable shoes and sandals," Kennedy says. "Often this can cause a conflict between what the patient desires and what is required for them to get the therapeutic benefits." Frequently, it is possible to meet these requests, he adds, depending on such variables as the specifics of the foot condition, the patient's lifestyle, and the doctor's prescription. "If the diagnosis is, for example, heel pain, sometimes an orthotic can be made to alleviate the symptoms without affecting shoe fit too much."

"If people want fashion footwear, they should be able to have it," Margiano says. "They may have to make some adjustments to accommodate foot-health concerns, such as wearing pumps instead of stilettos." He adds, "We can fabricate custom foot orthotics and heat-mold them to the shoe to fit its shape and style and adjust to the width and height of the heel."

Footwear manufacturers are also doing their part to make more foot-friendly shoes. Some popular styles not usually regarded as foot-health friendly, such as flip-flops, sandals, and some high-heel models now have earned the American Podiatric Medical Association (APMA) Seal of Acceptance. APMA's Seal of Acceptance program evaluates footwear, materials, insoles, hosiery, and equipment. Many footwear manufacturers are now making sandals and dressier footwear with full-length removable sockliners to accommodate custom foot orthoses, Marzano and Kennedy note. Margiano encourages consumers to invest in quality footwear to enhance fit and comfort, even if this means buying fewer shoes. He feels consumers are more conscious of taking care of themselves and their health than in the past, thus they are more willing to adjust fashion to foot care.

"In terms of sandals, several of the orthopedic shoe companies recently have developed fashionable sandals with fully removable depth inlays," Kennedy says. "Aetrex's Sandalistas and Birkenstock's sandals come to mind. Full, accommodative foot orthotics can be made for these sandals, and they have been well accepted by the podiatric community."

Kennedy adds, "Regular open-backed sandals, flip-flops, and other flimsy slip-on shoes are poor choices for orthotics. In such cases, when patients refuse to change their footwear, they are making a decision to suspend foot health for other considerations."

Custom Foot Orthotics

There are various ways to fabricate custom foot orthotics for popular shoe styles, Kennedy explains. Eliminating heel posts and using leather top covers makes orthotics less bulky. However, there is a trade-off: eliminating the rearfoot post reduces the stability and support, and thinner top covers come at the expense of cushioning and shock absorption. The orthotic shell can be machined more narrowly than the foot so that it sits down into the shank of the shoe. "However, with each compromise, some amount of control is lost," Kennedy says. "Some patients accept this, but the ones we really 'love' are those who argue to have it both ways. They want full control—and cushioning—and they want it to fit in their three-inch heels!" He adds, "Sometimes the doctor intervenes and insists on a particular design, in which case there are no choices."

Kennedy continues, "Women's high heels greater than two inches do represent unique issues, as the shoe shank is usually extremely narrow. The angle created by the excessive heel elevation requires that the orthotic be shaped very specifically, taking into consideration the pitch of the shoe. I feel that orthotics for stilettos are of very limited benefit, except perhaps for metatarsal pad relief."

Orthotics can be useful in some fashion footwear, Marzano says. However, he finds that educating patients about their footwear can help them to accept better choices. He tries to help them see how orthotics and shoes must work in unison to alleviate pain or help treat pathologies. He likes to use the analogy that a person would not build an upscale house on a foundation of quicksand to illustrate why fabricating orthotics for dress shoes often leads to disappointing outcomes.

"Many people don't realize how ill-fitting shoes can affect their whole body and its alignment, causing problems with knees, hips, back, and even their neck," Margiano points out, noting the importance of educating consumers.

"If you take the time to educate patients on how high-heeled or pointed-toed footwear is contributing to their pain and deformity, they often will come around and realize how the footwear they are wearing is causing their problem," Marzano says. "I normally spend more time talking to my patients about appropriate footwear than I do about the foot orthotics I am dispensing." He encourages patients to make a reasonable compromise, such as wearing dress shoes at work but more appropriate shoes with orthoses at other times.

The outlook is getting brighter for women who love glamorous high heels or don't want to give up those comfortable flip-flops and summery sandals. While some compromise between fashion and foot health may be unavoidable, the combination of more stylish, healthy footwear options from manufacturers and the skills of pedorthists and other foot-care experts is making it possible for more women to "have their shoes and wear them too."

Miki Fairley is a freelance writer based in southwest Colorado. She can be reached at