While podiatrists strongly advise patients to avoid wearing high heels, the reality is many patients will continue to wear them. With this in mind, this author emphasizes patient education on ensuring optimal fit and support, reviews key features to promote better stability, and discusses helpful shoe modifications.
Every podiatrist understands the potential for foot and ankle problems that are created when women wear high heels. Bunions, hammertoes, metatarsalgia, corns, calluses, neuromas, ankle sprains and ingrown toenails are all conditions we treat that are directly caused by or, at the very least, made worse by tight-fitting, high heeled shoes.
Unfortunately, even though we strongly advise patients to avoid wearing high heels, our words fall on deaf ears. The minute our female patients walk out of our office, their sensible shoes come off and the towering stilettos go back on their feet.
In an effort to at least meet our patients halfway, it is important that we are able to teach women how to make better choices when purchasing high heels and also how to improve the fit of these otherwise ill-fitting shoes. The following provides a foundation and some tools for you to share with your patients who insist on wearing high heeled shoes.
We all realize the last of the shoe determines the size, shape and certain style features of the shoe.1 Most patients understand that shoe sizes vary from manufacturer to manufacturer but there is a common misconception, especially among women wearing high heels, that sizing and fit within a brand are consistent and uniform.
For example, patients will often say, “I can only wear Nine West” or “I can only wear Steve Madden shoes” because they believe that all other brands of high heels do not fit their foot correctly. Nothing could be further from the truth. With any given brand, there will usually be some shoes that fit and others that do not fit. Our job is to educate patients about this fact and guide them toward styles or features appropriate for their particular foot type.
Educating Patients About Changing Foot Sizes
It is surprising how many women have their feet measured and sized as teenagers and never have them measured again. It is not uncommon for a woman to be wearing a size 7 when the actual current measurement is size 9. This is especially true if a woman has had children or gains or loses a significant amount of weight.
Equally surprising is when I ask patients what size shoe they wear, I often will hear them say a size 9 in athletic shoes and size 8 in high heels. Wearing shoes smaller than their measured foot size is one of the worst offenses I see women make when wearing high heels. If they consistently have to go smaller to keep a high heel on, there is something wrong with the design of the shoe.
Another area of misunderstanding is that of shoe size increments. Women are often shocked to learn that when they are correctly measured, they are one to two sizes longer than they thought they were. However, explaining to them that there is only 1/3 inch for each full size increase and 1/6 inch for each half size increase goes a long way to calming anxiety about having larger feet.2
Why Heel-To-Ball Is The Only Measurement That Matters With High Heels
The Brannock Foot-Measuring Device was patented in 1927 and is still the gold standard for foot measuring today.3 It determines both heel-to-toe and heel-to-ball or arch length.
Ninety percent of the women I see in my office are wearing the wrong size shoe, especially when it comes to high heels. Why? They are relying on heel-to-toe measurements. Unfortunately, heel-to-toe measurements are impossible to use as a guide due to the variability of toe-box lengths. When fitting high heel shoes, the only measurement that matters is heel-to-ball.
In my office, I use a couple of photos to illustrate this point. One image shows a properly fitting high heel, which has full arch support. Another image shows the same foot resting on a short heel-to-ball or arch length. In this image, the patient’s body weight is supported almost entirely by the first metatarsophalangeal joint (MPJ). Accordingly, there is a functional hallux limitus. When I show these images to my patients, they immediately understand why they have metatarsalgia, sesamoiditis or plantar fasciitis.
A short heel-to-ball fit typically occurs in one of two ways.
1) The arch of the shoe is too short for your patient’s arch either by style or size. This is the case where the foot measurement says size 9 and the patient is wearing a size 8 shoe. No matter how much padding is provided underneath the ball of the foot, this mismatch will always produce metatarsalgia.
2) The volume of the shoe exceeds the patient’s foot volume and her foot slides forward, losing heel-to- ball support. This is one of the main reasons high heels feel great in the shoe salon but are painful when people wear them outside. There are no hills in the shoe salon. There is only soft cushioned carpeting. Sliding does not occur until the patient walks down the first hill or quickly crosses the street. In this case, the height of the heel pushes the patient’s forefoot forward as she goes.
Volume mismatch will always produce heel slippage and applying heel grips to the inside counter of the shoe will do nothing to help in this case. This mismatch will also produce forefoot compression since the widest point of the forefoot has now slid to the more tapered part of the toe box instead of the widest point of the shoe.
This will also result in hammertoes due to the toes gripping as an attempt to stop the slide. Neuroma and bunion formation due to forefoot compression and metatarsalgia due to loss of support under the MPJs are inevitable in these cases.
Talking To Patients About Ensuring Good Fit
Due to the design of high heeled shoes, exact fit is required and women should settle for nothing less. The nemesis of a well fitting high heel shoe is the sale rack. Women too easily fall in love with an almost correctly fitting shoe that is on sale only to pay the price later with an otherwise avoidable injury. If women understand what to look for in a particular high heel shoe and how to achieve the best possible fit, they will not be so easily swayed by the sale rack.
Similar to an orthotic, the more surface area contact a shoe makes with the foot, the more support the foot will have. Women who are otherwise unable to wear a pair of 3-inch high heel pumps can be perfectly comfortable in a pair of 3-inch high heel boots if the heel-to-ball fit is exact. For many women, especially those needing to stand and walk for hours on end, this is a perfectly acceptable option.
T-strap styles and Mary Jane styles with an adjustable strap to secure the foot are also good choices for high heels. They keep the foot centered on the arch and prevent it from sliding forward into the narrower toe box part of the shoe.
Keys To Bolstering Stability With High Heels
The outsole width is a frequently overlooked part of the shoe yet it is crucial to proper fit and comfort when one wears a high heel. Many high heel outsoles taper in the waist and this is where midfoot support is needed the most. If the waist of a high heel significantly hourglasses in this area, gait will be unstable and the foot will fatigue more quickly due to a lack of support. Often, the difference between comfort and non-comfort high heels is the width of the outsole. Some high-end designers aware of this fact have recently begun to add a small medial flange to the insole of the shoe just for this reason.
Another way to improve stability is to make sure the pitch of the high heel is perpendicular to the ground. Some high heels are pitched forward, making the heel unstable and prone to breakage or shoe insecurity. The more posterior the heel is positioned, the better the stability.
The most stable high heel is one that has an inflexible forefoot, a firm heel counter and torsional stability. Platform styles in this regard are great as they give the illusion of height as well as torsional stability. Platforms typically have a wide outsole as well. Similar to when we show patients how to twist and flex their running shoes, we should do the same with high heels. The principles of motion control are one and the same.
Asking Patients To Take Comparison Shopping To Another Level
Women who wear high heels invariably have some that are comfortable and some that are not. To increase the odds of fit success, it is easy to teach your patients how to visually match future high heel purchases to current comfortable high heels in terms of design and fit.
In regard to the comfortable pair of high heels, what is the heel height (2 inches, 3 inches or 4 inches)? What is the design of the heel? Is it narrow and tapered, or chunky and squared? How wide is the waist in the comfortable pair? Does the waist hourglass? How wide is the forefoot in the comfortable pair? We need to teach patients to pass on heels that are not at least as wide in the forefoot as their most comfortable pair.
Does the throat line open high on the arch or closer to the toes? Asking these questions and using the answers to help guide future purchases by patients can go a long way to demystify for them why some high heels fit and others do not. You will be amazed when you discover that most high heel shoe wearers have never analyzed their shoes in this way before.
What You Should Know About Orthotics And High Heels
Even the lowest profile custom orthotic will inevitably raise the arch in a high heel, making it all but impossible to keep the foot and an orthotic securely in place due to the unstructured medial and lateral quarters found in most high heels. When a woman successfully wears a pair of sport orthotics, it is natural for her to want to have that support in her high heels.
Unfortunately, as easy as this should be, it never works out that way. I have treated dozens of unhappy female patients who are frustrated at having spent significant amounts of money on high heel orthotics from other practitioners that will not fit into their high heels. Instead, one can provide a narrow, thin, non-custom device that is specifically designed for high heeled shoes. My favorite brand of non-custom orthotic for high heels is the Superfeet® Women’s ¾ High Heel device (Superfeet). I dispense these orthotics from my office but they are also available at Nordstrom.
How To Prevent Heel Slippage
Men have used tongue pads forever but women seemed to have missed out on how to use this simple form of padding, especially when it comes to high heel shoes. As I noted earlier, the primary cause of heel slippage is due to the shoe having more volume than the foot. Consequently, the foot slides forward and the heel slips out.
To remedy this annoying problem, women frequently buy shoes that are too small since a smaller shoe has less volume and may help to minimize forward slide. When this type of heel slippage occurs, women mistakenly assume they have a narrow heel when what they really have is a shallow or low volume forefoot.
In this case, applying a simple tongue pad (of 1/8 inch black felt cut to size) to the underside of the vamp just distal to the throat line will keep the heel where it belongs, firmly against the inside counter of the shoe. I will apply this to one shoe first and have the patient compare it to the shoe without a tongue pad while walking down the hall. Your patients will be delighted at the effectiveness of the tongue pad.
An alternative method to prevent heel slippage is to use a toe comb, placing this dorsal to the toes instead of plantar. This also takes up volume and prevents forward sliding in the shoe. I typically use this when adhesive felt does not work.
Pertinent Insights On Shoe Modifications
Triplane wedge. Similar to how clinicians utilize the pediatric triplane wedge or the Kirby skive, one may apply 1/8-inch adhesive felt to the insole of a high heel shoe medially to limit calcaneal eversion at midstance.4,5 This is an easy in-office modification that can make a significant difference functionally.
Reverse Morton’s extension. Clinicians can add this directly to the insole of a high heeled shoe. I use lipstick to mark the first MPJ plantarly. Then I have the patient put her shoes on and walk down the hall to transfer this location to the insole of the shoe. I then fabricate a reverse Morton’s extension of 1/8-inch adhesive felt and apply it just lateral to the marked location, under the second, third, fourth and fifth metatarsals. Doing this improves first MPJ range of motion in conditions such as sesamoiditis and hallux limitus. If the felt is too thick, you can always peel off layers to reduce bulk. Once you show your patient how to do this, have her repeat the process with her other heels at home.
What About Shoe Stretchers?
Most shoe repair stores sell a limited variety of shoe stretchers. For patients who have bunions and hammertoes, a high heeled shoe stretcher can mean the difference between comfort and pain. Most patients are not aware there are a variety of shoe stretchers available for almost every challenging foot fitting need.
For high heels, there are specifically designed shoe stretchers in five different sizes (0-4). There are high heel vamp (sagittal plane) stretchers, high heel toe box (sagittal plane) stretchers and high heel width (transverse plane) stretchers. Shoe stretchers also have movable raised plugs and one can use these to spot stretch problem areas such as a bunion.
I recommend that patients use a shoe stretch spray first. Then I have them use the shoe stretcher and instruct them to leave the stretcher in overnight. If the shoe needs to be stretched more, they can repeat this process and leave the stretcher in place for another 24 hours. A shoe repair store can also do this but it is much more cost effective and convenient for patients to do this themselves.
The preceding recommendations are by no means exhaustive but are instead intended to foster a cooperative as opposed to adversarial relationship with our high heel wearing female patients. Unfortunately, designers and not podiatrists design high heels. It is also unfortunate that making a shoe look fashionable is not the same as making a shoe fit comfortably.
However, with a little common sense and gentle guidance, our most adamant high heel wearing patients can have increased comfort. If we are lucky, we can teach them how to avoid the pain but save the style.
Dr. Sanders is in private practice in San Francisco. Dr. Sanders pens a monthly blog for Podiatry Today (see http://www.podiatrytoday.com/blogs/594 ).
1. Rossi WA. The Complete Footwear Dictionary. Krieger Publishing Company, Malabar, Fla., 2000, p. 160.
2. Rossi WA, Tennant R. Professional Shoe Fitting. National Shoe Retailers Association, New York, 1984.
3. The Brannock Device Co., Inc. http://www.brannock.com/cgi-bin/start.cgi/brannock/instructions.html#fi…; . Accessed April 4, 2011.
4. Valmassy RL, Terrafranca N. The triplane wedge. An adjunct treatment modality in pediatric biomechanics. J Am Podiatr Med Assoc. 1986;76(12):672-5.
5. Kirby KA. The medial heel skive technique. Improving pronation control in foot orthoses. J Am Podiatr Med Assoc. 1992;82(4):177-188.
For further reading, see “Modification Tips: Making Sure The Shoe Fits,” in the August 2002 issue of Podiatry Today.