Foot and Ankle Surgery 22 (2016) 239–243

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Foot and Ankle Surgery

journal homepage: www.elsevier.com/locate/fas

Does the use of high-heeled shoes lead to fore-foot pathology?

A controlled cohort study comprising 197 women
Grethe E. Borchgrevink a,*, Annja T. Viset b, Eivind Witsø a, Berit Schei c,d, Olav A. Foss a
a
Department of Orthopaedic Surgery, St. Olavs University Hospital, Trondheim, Norway
b
Department of Radiology, St. Olavs University Hospital, Trondheim, Norway
c
Institute of Public Health and General Practice, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
d
Department of Obstetrics and Gynaecology, St. Olavs University Hospital, Trondheim, Norway

A R T I C L E I N F O A B S T R A C T

Article history: Background: High-heeled shoes have been suggested as a main explanation for the female dominance in
Received 11 June 2015 foot pain and deformities. Aim of study was to test this hypothesis scientifically.
Received in revised form 8 October 2015 Methods: Women 40–66 years were included in two groups. 95 women who had worn high-heeled
Accepted 28 October 2015
shoes at work for at least 5 years were compared to 102 women who had never worn high-heeled shoes
at work. The investigations were weight bearing radiographs of foot and ankle, the SEFAS questionnaire
Keywords: and the AOFAS Clinical Rating System. Evaluators were blinded to the group-affiliation.
Footwear
Results: Radiographs showed no statistically significant differences between the two groups concerning
High-heeled shoes
Hallux valgus
deformities or joint disease. Foot function measured by SEFAS and AOFAS total score, were similar in the
Foot deformities two groups. The high-heeled group had more pain and more callosities.
Foot pain Conclusion: For women aged 40–66 years wearing of high-heeled shoes had not caused foot
deformation, but more foot pain and callosities.
ß 2015 The Authors. Published by Elsevier Ltd on behalf of European Foot and Ankle Society. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction 2. Materials and methods

Women contact health professionals for foot disabilities twice as
often as men [1]. Among patients undergoing surgery for hammer-
toes and hallux valgus, studies have shown that nearly 90% are
women [2,3]. It is commonly assumed that the long term use of high-
heeled shoes may lead to chronic foot pain and deformities and some
studies have suggested that this type of shoe explains the
predominance of foot problems among women [4,5]. Biomechanical
studies have shown that the vertical ground reaction force, ankle
plantar flexion, maximum anteroposterior braking force, and
forefoot loading is increased by wearing high-heeled shoes [6–
8]. Based on theoretical consideration, it is reasonable to believe that
wearing high-heeled shoes may lead to foot disabilities. However,
the results of previous clinical studies on women wearing high-
heeled shoes are conflicting [9–12]. The aim of this study was to
assess whether women reporting to wear high-heeled shoes at work
are more likely to report foot pain, have more foot deformities and
poorer foot function than women who never use high heeled shoes
at work. Our hypothesis was that high-heeled shoes cause pain and
foot-deformities.
We included two groups of women; a high-heeled group and a
control group, and based on statistical power calculation we aimed
to include 100 women in each group (see Section 2.4).
2.1. Inclusion/exclusion criteria
The inclusion criterion for the high-heeled group was women
who had used high-heeled shoes regularly at work for 5 years or
more. A high heel was defined as 5 cm or higher. The women who
served as the control group stated they had never used high-heeled
shoes at work. Only women between the ages of 40 and 66 years
were included, as arthritis, deformities and soft tissue disabilities
and foot pain are uncommon before the age of 40 [1,13]. The upper
age limit was chosen because the official retirement age in Norway
is 67 years. All women who had been previously operated in the
foot or ankle were excluded.
2.2. Recruitment process

We used a brief recruitment form distributed to shoe-shops and

* Corresponding author. Tel.: +0047 72826084. work-places such as banks, hotels and hair-dressers during the
E-mail address: Grethe.Borchgrevink@stolav.no (G.E. Borchgrevink). period October 1st to December 31st 2012. An electronic version of

http://dx.doi.org/10.1016/j.fas.2015.10.004
1268-7731/ß 2015 The Authors. Published by Elsevier Ltd on behalf of European Foot and Ankle Society. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
240 G.E. Borchgrevink et al. / Foot and Ankle Surgery 22 (2016) 239–243
the recruitment form was also published on our hospital’s website.
Women were asked how many years they had used high-heeled
shoes at work and also the number of days they had been wearing
high-heeled shoes during leisure time the week prior to
completing the form. We excluded 70 of the 927 responders
because they had not given their phone-numbers, 492 did not fulfil
our age criterion and 17 had used high-heeled shoes at work for
less than 5 years. Fig. 1 shows the flow chart of the recruitment
process for the remaining women. The women were called by
telephone in a random order based on a list put together by an
administrative aid. All of the 144 women that satisfied the
inclusion criteria in the high-heeled group were contacted. A
sample (146 of the 204 potential controls) randomly selected by
the administrative aid was likewise contacted.
2.3. Examinations
The clinical and the radiological evaluations were performed
blinded to the group-affiliation. The clinical examinations were
performed by the principal investigator (GEB) and the radiological
investigations were evaluated by a single radiologist (ATV). A total
of 205 women were investigated; 100 from the high-heeled group
and 105 controls.
Weight bearing radiographs were obtained in sagittal and
anterior-posterior projections of the foot and ankle bilaterally. The
hallux valgus angle and the inter-metatarsal angle between first
and second ray were measured from the AP projections. For hallux
rigidus the Menz scoring system was used [[2_TD$IF]14]. Grade two or more
was recorded as hallux rigidus.
As measurements of general foot function the total score of
SEFAS (Self-reported Foot and Ankle Score) and AOFAS (American
Orthopaedic Foot Ankle Society) instruments were used.
When attending the clinical assessment, the women were asked
to fill in the SEFAS questionnaire [[3_TD$IF]15] that contains 12 items which
are scored concerning pain, function, and limitation of function.
[(Fig._1)TD$IG]
Fig. 1. Recruitment flow chart.
The scores range from 0 to 4, with 4 as the best score yielding a
maximal score of 48.
The AOFAS Clinical Rating System for ankle, mid-foot, hallux
and lesser toes were completed [[4_TD$IF]16]. It combines information from
the patients as well as results from the clinical examination. For
each anatomic site, pain, function and limitation of function are
noted. The clinical examination includes gait abnormalities,
motion, stability and alignment. Each item has a maximum score
between 5 and 40 and is summarized to give a total score between
0 (worst) and 100 (best) for each of the four anatomical areas.
Alignment in the hind-foot and the lesser toes was examined in
accordance with AOFAS in a tree scale system. To distinguish the
different foot types we used a mirrored photo-box. The sagittal
range of motion in the ankle (flexion plus extension) was measured
with a goniometer in degrees. Callosities were recorded as existing
or not, regardless of symptoms, under the metatarsal heads on the
sole of the foot.
2.4. Statistics
As foot pain has been found to be around 20% in the general
population [1,13] we chose pain as our main outcome. Statistical
power calculation was based on a supposed 20% increased amount
of pain in the high-heeled group. It was calculated that 82 women
had to be included in each group to obtain a = 0.05 and b = 0.80,
IBM (Sample-power version 3). We aimed to include 100 women in
each group. The statistical calculations were performed using IBM
SPSS Statistics version 21. First, pain measurements from AOFAS
were dichotomized into no pain or any pain in one or both feet and
statistically analysed using the Pearson’s chi square test. Second,
we analysed pain in each foot in accordance with AOFAS in a four
level ordinal scale system (severe/almost always present, moder-
ate/daily, mild/occasional and none) from each of the four regions;
lesser toes, hallux, mid-foot and the ankle, from each foot. Linear
Mixed Models (continuous outcomes) and Generalized Linear
Mixed Models (categorical outcomes) were used to account for the
data dependency caused by the two-level structure; feet, (level
one) nested within persons, (level two). Alignment in the hind-foot
and the lesser toes were analysed in a three levels ordinal scale.
Callosities and hallux rigidus were analysed as binominal data. The
hallux valgus angle, the inter-metatarsal angle and the range of
motion in the ankle were analysed as continual variables. Akaike’s
information criterion was used to identify the most parsimony
models [17]. Visual inspection of Q–Q plots were used to
investigate if data were normally distributed. The age and total
scores from AOFAS and SEFAS were not normally distributed and
analysed using the Mann Whitney test (the total scores from
AOFAS and SEFAS were compared between the groups as the mean
score from the right and left foot from each individual). For the
other measured continuous outcome parameters the residuals
were found normally distributed. The statistical level of signifi-
cance was set to P less than 0.05 (in the tables marked with *).
2.5. Ethics
The study was approved by the Regional Committee for Medical
and Health Research Ethics (REC 2012/1185b). Informed consent
was obtained from all individual participants included in the study.
3. Results
Eight women were excluded due to previous foot-and ankle
operations, leaving 95 women in the high-heeled group and 102 in
the control group.
There was no statistically significant difference in age between
the two groups (P = 0.60). In the high-heeled group median age was
 G.E. Borchgrevink et al. / Foot and Ankle Surgery 22 (2016) 239–243 241

Table 1
Alignments, callosities and radiological findings.

High-heeled Control group P-value Odds 95% CI

group 190 feet 204 feet ratio

Alignment according to AOFAS

Hindfoot Good 128 135 P = 0.996 0.999 0.53–1.88
Fair, no symptoms 55 64
Poor, with symptoms 7 5

Lesser toes Good 152 152 P = 0.33 0.71 0.35–1.42

Fair, no symptoms 28 40
Poor, with symptoms 10 12

Hallux rigidus Yes No Yes No P = 0.40 0.72 0.33–1.57

21 169 30 174
Callosities:
Lesser toes 109 81 81 123 P = 0.008* 2.39 1.25–4.56
Hallux 121 69 30 174 P < 0.001* 3.19 1.68–6.06

Measurements in degrees:
Hallux valgus angle Mean P = 0.12
12.1 13.3
95%CI
11.0–13.1 12.2–14.3
Intermetatarsal angle Mean P = 0.67
9.6 9.7
95%CI
9.2–10.0 9.3–10.1
Range of motion in the ankle Mean P = 0.07
79.0 75.9
95%CI
76.6–81.5 73.5-78.2

50 years (25–75 percentiles: 45–56) and in the control group
51 years (25–75 percentiles: (44–58).
In the high-heeled group the median use of high-heeled shoes
at work was 20 years (25–75 percentiles: 10 -30). This group used
high-heeled shoes more frequently also at leisure time during the
week prior to completing the forms, 78% compared to 28% in the
control group (P = 0.000).
There were no significant differences between the groups in
the radiological measurements of the hallux valgus angle
(P = 0.12, Table 1). We found no effect to the hallux valgus angle
when we used as co-variants the number of years using high
heeled shoes at work (P = 0.88), or the number of days using high
heeled shoes during the previous week (P = 0.55). Fig. 2 shows
the scatter plot of hallux valgus angle versus the number of years
of using high heeled shoes at work. There were no significant
differences in the observed alignment in the hind-foot and lesser
toes, the prevalence of hallux rigidus or the inter-metatarsal
angle (Table 1). The range of motion in the ankle was reduced in

[(Fig._2)TD$IG]

Fig. 2. The Hallux valgus angle in accordance to the number of years the women had worn high-heeled shoes.
242 G.E. Borchgrevink et al. / Foot and Ankle Surgery 22 (2016) 239–243

Table 2 The high-heeled group had statistically significantly more

Total score AOFAS and SEFAS (the mean score from the right and left foot).
callosities under the head of the first metatarsal (P < 0.001) and
AOFAS High-heeled group Control group P-value beneath the metatarsals of the lesser toes (P = 0.008) (Table 1).
95 women 102 women We also performed all the statistical analysis after exclusion of
Median 25–75 Median 25–75 30 women with conditions such as rheumatoid arthritis, diabetes
Percentiles percentiles mellitus and disk herniation, known to be at risk for foot-problems.
Lesser toes 94 85–98 95 83–100 0.27 The results remained unchanged concerning which comparisons
Hallux 89 75–98 93 81–100 0.10 that were statistically significant (data not shown).
Midfoot 93 85–100 96 90–100 0.24
Ankle 94 86–97 94 89–97 0.74
4. Discussion
SEFAS 44 39–47 46 40–48 0.27

4.1. No foot-deformities
Table 3
Pain from AOFAS questionnaire—presented as dichotomized data; no pain or any We found no statistically significant differences between the
pain in one or both feet. groups with regard to anatomical deformations of the feet.
Nguyen et al. [11] studied hallux valgus to associated factors such
Pain High-heeled group Controls P-value
as sex, race, education, BMI, pain, pes planus and the wearing of
n: 95 (%) n: 102 (%) types of shoe. They found that women reporting to have worn
Lesser toes Any 36 (37.9) 28 (27.5) P = 0.12 high-heeled shoes with heels of 2 in. or more as their usual shoe
No 59 (62.1) 74 (72.5) between 20 and 64 years of age had ‘‘20% increased likelihood of
Hallux Any 45 (47.4) 40 (39.2) P = 0.25 having hallux valgus’’ compared to women who had not. Dawson
No 50 (52.6) 62 (60.8) et al. [9] when interviewing women and making an inspection of
Mid-foot Any 40 (42.1) 29 (28.4) P = 0.04* their feet did not find statistically significant more foot
No 55 (57.9) 73 (71.6) deformities among the 25 women who had worn high-heeled
shoes at work compared to the 96 women who had not, but found
Ankle Any 36 (37.9) 36 (35.3) P = 0.71
No 59 (62.1) 66 (64.7) more presence of hallux valgus among those who had started to
wear high-heeled shoes at a lower age. Menz and Morris [10]
studied footwear among 176 people with mean age of 80 years.
Table 4 Out of the 120 women, 26 wore high-heeled shoes (defined as
Pain from AOFAS questionnaire—presented in a four level ordinal scale system
2.5 cm). In their study current users were likely to have more
(severe, moderate, mild and none).
hallux valgus. However, they found no such association was
High-heeled Controls P-value Odds 95% CI found when assessing 120 women with a past history of wearing
group 204 feet ratio
high heels.
190 feet
It can be expected that wearing of high-heeled shoes will cause
AOFAS tightness and shortening of the calf muscle and subsequent
Lesser Severe 2 1 P = 0.04* 2.15 1.03–4.46
decrease in the range of motion in the ankle. Contrary to this we
toes Moderate 16 11
Mild 45 32 found less ankle motion in the control group, however, we did not
None 127 160 perform separate measurements for plantar flexion and extension
Hallux Severe 4 2 P = 0.07 1.53 0.97–2.42
Moderate 31 19 4.2. More pain
Mild 43 42
None 112 141 We found that the high-heeled group suffered more pain than
Midfoot Severe 3 4 P = 0.02* 2.45 1.16–5.16 the controls in the lesser toes and the mid-foot. A potential
Moderate 14 6 explanation for the pain in the mid-foot is the windlass
Mild 54 34 mechanism; wearing high-heeled shoes flexes the MTP joints
None 119 160
and may cause painful tension in the plantar fascia. These findings
Ankle Severe 1 4 P = 0.46 1.27 0.67–2.40 are in contrast to Paiva de Castro et al. [12] who found no
Moderate 11 11 association between foot pain and the use of high-heeled shoes.
Mild 47 35
They studied the relationship between foot pain, anthropometric
None 131 154
variables and footwear among 227 older women who were divided
into four groups according to their habit with regard to wearing
high-heeled shoes.
the control group, however not statistically significant (P = 0.07,
Table 1). 4.3. More callosities
The total scores from AOFAS and SEFAS (Table 2) did not differ
statistically between the groups. We found that the high-heeled group had more callosities
The high-heeled group reported statistically significantly more compared to the controls. Callosities are caused by increased local
pain compared to the controls (Table 3 and Table 4). When pain pressure [18]. The wearing of high-heeled-shoes increases the
was dichotomized (Table 3) we found a statistically significant loading in the forefoot and it is also shifted medially [6–8]. This
difference in the mid-foot as 42% of the women in the high-heeled harmonises with our finding that there were more callosities in the
group reported pain in one or both feet compared to 28% in the high-heeled group in the forefoot, and mostly medially.
control group (P = 0.04). When pain was assessed using AOFAS in a
four scale system, analysed from each anatomical region and 4.4. Other potential explanations for the female dominance
compared using a mixed model (Table 4), the high-heeled group
had statistically significantly more pain in the lesser toes (P = 0.04) Some have suggested a lower pain tolerance [13] or looser
and the mid-foot (P = 0.02). ligaments [19] among women as explanations for the female
 G.E. Borchgrevink et al. / Foot and Ankle Surgery 22 (2016) 239–243
dominance in foot problems. Studies have reported that narrow
shoes may cause hallux valgus, pain and ulcerations independently
of the height of the heel [10,12,20,21], and the female dominance
in foot problems might depend on the overall use of ill-fitting
shoes. In this study we did not ask about the shape of the shoes
because this differs over time with fashion. Furthermore we did
not focus on the reported increased risk of injuries to the foot and
ankle caused by wearing high-heeled shoes [22,23]. We only
explored the long-term effect of using high-heeled shoes.
4.5. Methodological weaknesses
In the recruitment process we advertised a free examination of
the feet, and some women with foot pain might have seen this as
an extra benefit, and this may have caused a bias towards more
pain and foot deformities than in the general population.
Furthermore we could not find any published studies assessing
the score of SEFAS and AOFAS in non-patient populations, and
another methodological weakness may be that these instruments
are not primarily developed to detect differences in foot problems
in non-patient populations.
5. Conclusion
We found no evidence that high-heeled shoes leads to
reduced function, anatomical deformities or joint disease in
the feet of an otherwise healthy female population aged 40–66
years. However, more foot pain in the lesser toes and the mid-
foot and more callosities was seen in woman wearing high-
heeled shoes.
Conflict of interest statement
We confirm that none of the authors have any conflict of
interest.
Acknowledgements
We want to thank the radiograph technicians and secretaries at
the Department of Radiology and the staff at the Orthopaedic
outpatient clinic at St. Olavs University Hospital, Trondheim,
Norway. We also want to thank Vilhjalmur Finsen, Kjetil Hvaal, Jan
Lidström and Maria Cöster for their help. The conduct of the study
was partially funded by Trondelag Orthopaedic Workshop and we
want to thank them for their financial contribution. Trondelag
Orthopaedic Workshop was not involved in the study design, data
collection, data analysis/interpretation, writing of the article nor
the decision to submit the article for publication. There were no
other sponsors of the study.
243
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