A primary step in the evolution of plantigrade, bipedal human gait was the development of the Medial longitudinal arch (MLA). It is considered as a terrestrial modification of the arboreal foot. It has two important effects; firstly, it provides the plantar flexor muscles enough mechanical advantage to lift the weight of one's body during stance, and secondly, it provides one's foot with the capacity to absorb shock caused by upright striding.
The arches of the foot are transverse arch and longitudinal arch; the longitudinal arch includes the Medial longitudinal arch (MLA) and Lateral longitudinal arch (LLA). The MLA is formed by bones, ligaments, and tendons. The summit of this arch is the talus which is a keystone. The anterior pillar is formed by the heads of the medial three metatarsals, and the posterior pillar is made by medial half of the calcaneus. It is designed by the joints of various bones – the tarsals, metatarsals, and phalanges; this results in ideal transmission of the body weight, and permits adjustments among joints on uneven surfaces. The ligaments, plantar calcaneonavicular ligament (spring ligament) and interosseous ligaments, provide elasticity to the arch which helps in restoring the shape once the disturbing force is removed. Alterations in the normal configuration of the arch cause altered biomechanics in transmitting the body weight and may result in stress and strain over the weight-bearing bones, ligaments, and the most vulnerable part of the arch – the talocalcaneonavicular joint – and cause long-term pain in the foot.
When the medial longitudinal arch of the foot is obtained on a lateral roentgenogram, its configuration is evaluated by measuring lateral talocalcaneal angle, lateral talar-first metatarsal angle, calcaneal inclination angle, angle of the longitudinal arch, etc., Fashion has modified the design of the shoes to a point such that the actual function of shoes has become compromised. High heels greatly affect the joint kinetics during walking that may cause abnormalities in the foot. The weight borne with each step becomes concentrated on the metatarsal heads, mostly the first metatarsal.
While wearing heels, a person's hips and spine are out of alignment causing an increase in pressure on knees and feet. This results in unsteady gait (in order to maintain center of gravity), restricted running and a change in posture, especially when requiring a more upright posture. They make the wearer appear taller, smarter, and confident; they make the legs appear longer; they make the foot appear smaller; they make the lower leg muscles and gluteus maximus more defined; and they make the arches of the feet higher and better defined. As the great toes extend, plantar fascia is stretched which increases the height of the arch and the calf-to-calcaneus angle decreases as in normal windlass mechanism in the foot. However, high heels prevent the normal flattening during the gait cycle.
Women complain of lower back pain and foot pain and feel inconvenienced by heights between 2.5” and 3.5” (6–9 cm) due to the fact that when the foot slants forward, a large amount of body weight shifts to the ball of the toes resulting in damage to the underlying soft tissues and ligaments of the sole. Long-term use of high-heeled shoes disrupts the arches and causes changes in the plantar pressure distribution and gait. It possesses a major risk factor for musculoskeletal problems such as ankle sprains by slips and falls, heel pain, lower back pain, muscle fatigue, ligament tears, hyperkeratotic corns and callosities, shoe bites, plantar fasciitis, hallux valgus (hammertoes), or bunions.
Till date, studies of the effects of wearing high heels have concentrated only on musculoskeletal, kinetic, kinematic, neural parameters; gait; plantar arch index evaluation by foot impressions; venous function; or psychosocial behavioral aspects.
The aim of this study was to document the influence of high-heeled shoes on the medial longitudinal arch of the foot by radiographic methods taking into account body mass index (BMI), height of heels, and type of shoes worn, and correlating it with the presence or absence of back and foot pain.
Material and Methods
This study was conducted in the Department of Radiology of our hospital. Ethical clearance was obtained from the Institutional Review Board prior to the start of the study (IRB No.: 2019/26/003).
A total of 80 women in the age group of 18–25 years were included in two groups:
- Group 1 (test): 40 habitual high-heeled footwear users
- Group 2 (control): 40 flat footwear users.
Women with history of trauma to lower limbs, any skeletal deformities of lower limbs, pregnant women, and women of age less than 18 years or more than 25 years were excluded from this study.
Prior to testing, participants were informed about the procedures and informed consent was obtained. A case report form/questionnaire was provided to each participant to enter their personal and demographic details.
Duration of usage of high heels and height and type of footwear were noted in addition to their body weight and height. History of low back pain and foot pain was also documented.
This observational study was conducted over a period of 2 months (June–July 2019). As per Neil J. Cronin, participants with a history of wearing minimum heel height of 2” for at least 40 hours per week, for about 2 years were included in “test” group, and the women who wore flat footwear or heels occasionally or rarely for less than 10 hours in a week were included in “control” group.
Foot, on standing, performs static function by giving weight-bearing support and while walking it performs dynamic function by propelling the body weight forwards. There are many ways for measuring the MLA both statically and dynamically although it is a controversial issue and there is no universally accepted clinical or radiological method. The methods can be classified into direct and indirect methods. Direct methods are anthropometric and radiographic evaluations, while indirect methods are footprint and photographic analyses.
Our study uses the technique of measurement under the static and direct (radiographic) method for the reason stated by Saltzman et al. mentioned below in the discussion.
Lateral radiographs of right and left feet of both the test and control groups were taken in weight-bearing position. Lateral talocalcaneal angle, lateral talar-first metatarsal angle (Meary's angle), angle of longitudinal arch, and calcaneal inclination angle (calcaneal pitch), as shown in Figure 1, were measured by a protractor and goniometer separately, and compared between the two groups.
Standard techniques were employed in taking the lateral view. Subjects stood on a wooden platform with the medial border of the foot touching the cassette or detector plate in weight-bearing position. Proper precautions were taken, keeping in mind the harmful exposure of x-ray radiations.
The X-ray tube was placed parallel to the wooden platform with the central beam targeted on the base of fifth metatarsal. The X-ray film was kept at a distance of 54” and the radiation exposure given was 8 mAs at 50 kV. The cassette size was 12” ×10” placed in landscape orientation.
All radiological measurements were independently measured by two different individuals to minimize manual and parallax errors, and care was also taken to eliminate magnification errors.
Data obtained were subjected to Independent sample t-test and Pearson's correlation analysis available in Statistical Package for the Social Sciences (SPSS) 17.0 statistical software, Chicago, USA. Level of statistical significance was fixed atP<0.05.
Eighty, apparently healthy, female students were enrolled for this study. They were divided into two groups depending on the use of high heels. Test group included students who regularly used high-heeled footwear (40 students) and control group included students who did not use high-heeled footwear regularly (40 students). [Table 1] gives the mean values of the age, height, weight and body mass index (BMI) of both the groups. Independent sample t-test statistics between the two groups is shown in Table 2. The mean values of all angles except left lateral talar-first metatarsal angle fall in normal ranges. The left lateral talar-first metatarsal angle showed a statistically significant difference (P=0.017) between the test and control groups. The other angles did not show any statistically significant difference between the two groups.
The results of the correlation analysis between foot angles and BMI did not show any statistically significant correlation as shown in Table 3.
Correlation with low back pain
Left lateral talocalcaneal angle shows a significant negative correlation (r=-0.327; P=0.04) and right lateral talar-first metatarsal angle shows a significant positive correlation (r=0.327; P=0.039) with the presence of low back pain in those who wear high heels, as shown in Table 4.
Correlation with foot pain
All the foot angles measured did not show any statistically significant correlation with the presence of foot pain in individuals who were high heels, as shown in Table 5.
[Figure 2] shows that 17.5% of individuals experienced low back pain due to the usage of high-heeled footwear.
Foot pain was seen in 37.5% of individuals who regularly used high-heeled footwear, as shown in Figure 3.
[Figure 4] shows the number of individuals wearing different footwear with variable height of heel. Twenty-seven individuals wore heels of >2.5” height.
[Table 6] gives the information regarding percentage of different types of heels worn by participants included in Group 1.
The medial longitudinal arch height is one of the important criteria for classifying configuration of the foot into pes rectus (normally aligned foot), pes planus (flat foot), and pes cavus (high-arched foot). It is important for evaluating foot functions.
As mentioned in a study, the arch tends to elevate into a high arch within 2–5 years of wearing high heels and then tends to flatten within 6–10 years and tends to collapse into a flat foot in more than 20 years of wearing high heels.
Clinically, measurement of the arch involves measuring the soft tissue or bony landmarks of the foot with respect to straight horizontal surface. However, variations in the shape of the foot make it difficult for accurate identification and palpation of these landmarks. This shows concern about the validity and reliability of such manual measurements. Therefore, Saltzman et al. considered the radiographic measurement of the arch structure as the “gold standard” for three reasons. Firstly, it provided a clear two-dimensional image of the skeletal components. Secondly, the reliability is high. And thirdly, correlation between foot radiographic parameters and injury of the lower extremities can be made out.
Lateral talocalcaneal angle, lateral talar-first metatarsal angle (Meary's angle), angle of longitudinal arch, and calcaneal inclinational angle (calcaneal pitch) were measured in the lateral view roentgenogram to evaluate the medial longitudinal arch of the foot.
The following angles were measured as described by Simons, Vanderwilde et al.,
- The lateral talocalcaneal angle [Figure 5] is formed by joining the line bisecting the talus with the line along the axis of the calcaneus. A line is drawn at the inferior border of the calcaneus. The other line is drawn through two midpoints in the talus; one at the body and one at the neck. The normal range is 25°–45°
- The lateral talar-first metatarsal angle (Meary's angle) is formed between the long axis of the talus and the first metatarsal [Figure 6]. In the normal foot, the midline axis of the talus is in line with the midline axis of the first metatarsal, i.e. the angle, n=0°. An angle of more than 4° with convexity facing downwards, is considered as pes planus; an angle of more than 4° with convexity facing upwards, is considered as pes cavus.
- The calcaneal pitch [Figure 7] is defined as the angle formed by the intersection of a line drawn tangentially along the inferior border of the calcaneus and a line drawn along the inferior/plantar surface of the fifth metatarsal head. There is a debate on normal range, but anything between 17° and 32° is considered normal
- The angle of longitudinal arch [Figure 8] is formed between the calcaneal inclination axis and a line drawn along the inferior edge of the fifth metatarsal. The normal range is 150°–170°.
The results of our study showed statistically significant changes in lateral talar-first metatarsal angle of women who wore heels habitually, implying that wearing heels even for less than 2 years can bring about some changes in the arch height, although elevation or collapsing of the arch was not seen in our study sample and it is expected only in those who wear heels for a longer period of time. Our study group had college students who mostly wore wedges/platforms/flatforms/block heels for an average of 7–8 active working hours for about 2 years, with an average height of heel being 2.706”.
Other angles did not show significant changes and they were all in normal ranges of the angles, meaning no major arch changes with respect to these angles were seen. In a similar study by Wadee, changes were seen, but only in some foot angles: changes in lateral talar-first metatarsal angle, calcaneal pitch angle (in lateral view), and talonavicular (in anteroposterior [AP] view) were seen; while lateral talocalcaneal angle remained unchanged. He concluded that wearing 2” heels for about 8 weeks had an impact on the foot angles.
There is a variety of footwear available with considerable variation in design and shape of the heel. Our questionnaire recorded the height and type of heels worn because more the heel height, more is the pressure applied on the balls of the toes and sole. 1” heel increases pressure by 22%, 2” heel increases pressure by 57%, 3” heel increases pressure by 76%, and the type of heels will determine the degree of compression of the toes and inclination of the plantar surface from the horizontal surface by the shoe.
High heels vary from a kitten heel of 1”–2” to a stiletto heel of 4” or more. Extremely high-heeled shoes >5” are usually worn only for esthetic reasons and are mostly impractical. High heels lie between 3.5” and 5” while mid-heels lie between 2.5” and 3.5” and low heels are <2.5”. A graph representing the height of heels in our study population is shown in Figure 3, and [Table 6] shows the percentage of women wearing each type of heels, with wedges and flatform/platform heels being the most popular.
As concluded by Borchgrevink GEet al, high heels caused foot pains and callosities but no anatomical foot deformities. Our study also reported 37.5% of women who wore high heels complained of foot pain, of which 33% were sure that the pain was caused by wearing heels, 60% were not sure, and <6% said that the pain was not because of wearing heels [Figure 3]. 17.5% of women also complained of having low back pain [Figure 2].
Our study showed changes in the anatomical structure of the arch with significant chnages in lateral talar-first metatarsal angle.
It can be seen that wearing wedges/platforms/flatforms caused less foot pain and back pain, suggesting that these types of shoes are comparatively better than pointed high heels like stilettos as the pressure is distributed along the entire plantar surface and provides more body balance, unaltered gait, and comfort.
Our study also showed that there was a negative correlation seen with complaints of low back pain in relation to lateral talocalcaneal angle, indicating that as the angle decreased, low back pain increased and vice versa. Further positive correlation was seen with right lateral talar-first metatarsal angle, which indicates that low back pain proportionally increased with increase of angle.
Since both the study groups complained of foot pain irrespective of the type of footwear used, it could not be considered of any significance in our study.
Limitations of this study
Further studies need to be done in women who wear heels for more than 2 years duration, with more focus on those who use pointed type of high heels, so as to find out if any significant changes exist in other major foot angles.
Our study was limited to taking lateral view of X-rays; future studies using antero-posterior (AP) view of X-rays to measure foot angles can also be done; comparison between weight-bearing angles to nonweight-bearing angles can also be done.
In addition, we have used the goniometer, which is a manual method of calculating angles due to unavailability of software and experience to handle advanced technology; further studies can be done using online software such as AutoCAD, Microsoft, and Orthopractis or by using computed tomography scans.
The findings obtained in our study indicate deleterious orthopedic changes in the plantar arch and gait because of increased stress on the foot on prolonged usage of high-heeled shoes. In addition, forcing toes into a small shoebox, can cause or worsen conditions such as corns, hammertoes, bunions, and Achilles tendinitis, along with raised concern over the presence of foot and low back pain.
In agreement with Joseph Sachithanandam, we can conclude that if one wears high heels over 2” regularly, then they are more likely to develop chronic foot problems and working with them for 8 h or more in a day over a long period of time (>2 years) may lead to an altered foot arch.
This study would suggest women to use footwear with wedges/platforms/flatforms or heels less than 2” height, and to keep it occasional. It would also help young women change their lifestyle and choose appropriate footwear so as to avoid bony pains and anatomical deformities in future.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
This study was partly supported by the Indian Council of Medical Research (ICMR) Short Term Studentship awarded to Ms. Saimah Naseer (ICMR STS Reference ID: 2019-03654).
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