Health Science Journal

Keywords

Forefoot pain; High heeled shoes; Gait; Forefoot pressure

Introduction

The forefoot is the part of the foot containing the metatarsal bones and phalanges, the front part of the foot (Medical dictionary, 2012). Pain in this region can be caused by many factors; out of them, one is wearing high heels [1-9]. Nearly, 59% of females carry high-heel for 1-8 hours daily [10]. The position of the foot in high heels puts strain which causes harmful effects on foot structure [6]. If the height of the heel is increased up to 2 and a half inches pressure on the forefoot is increased by 75% [5]. A previous study reported that 83% of foot issues are accounted for in ladies wearing high-heeled shoes as it prompts changes in load distribution by walking [7]. Because of high-heel shoes loading on forefoot tend to be increased and are diminished on the rear foot [9].

As a biomechanical aspect, shoe wear plays a significant role in the process of walking and standing. Heel height, as well as the thickness of the sole, may impact the distribution of weight and consequently affect locomotion [1]. With the increasing height of the heel, the center of gravity displaces forward due to greater than before plantar flexion at ankle joint, resulting in forefoot stress [8]. Disturbed biomechanics leads to pain discomfort and other pathologies. Previous literature showed a significant association of foot pathologies with high heels, but very few studies have been found to highlight the relationship between high heels and forefoot pain. This study focuses on the said prevalence among female teachers and students of different universities in Faisalabad.

Material and Methods

The study was conducted at various universities of Faisalabad including Government College University Faisalabad, Agriculture University of Faisalabad, Government Women University Faisalabad and The University of Faisalabad. The population included in this study comprises of female teachers and students who regularly wear high heels. The sample size of this study was based upon a previous controlled cohort study conducted by Borchgrevink et al. [2]. Sample size drawn for this cross sectional study was 200 females. The population included in this study was very diverse, so the most convenient simple random sampling technique was used. Sample selection was done carefully on the basis of preset inclusion and exclusion criteria.

Inclusion criteria

• Females

• Teachers and students

• 18-40 years of age

• Wearing high heels regularly on working days (Borchgrevink et al., 2016)

• Heel height at least 2.5cm-5cm and above. Exclusion criteria

• Post-traumatic foot pain

• Previously operated ankle or foot

• Age >40 years

• Females not wearing high heels

Data collection tool was a self-generated questionnaire that was derived from the SEFAS questionnaire including their demographics, questions related to the frequency of wearing high heels, the height of heels and intensity of pain. A questionnaire was filled after taking consent from the participants. Statistical analysis and interpretations were done by SPSS version 23.0.

Results

Most respondents belong to the age group 18-23 years (77%), while 16.5% belong to the age group 24-29 years. 30-35 years of age group comprises only 5% of the total sample size. Only 1.5% consists of 36-40 years of age group.

Majority of respondents belonged to the student population which comprised of 82% while teachers were only 18% of the total sample size. Students were a major part of this study’s sample owing maximum percentage.

Question 1: Since how long are you wearing your high heels?

Table 1 showed that females wearing high heels for 5 years or more were a major part of the percentage (30%) while those who were wearing for less than one year were comprising 24.5%. 22.5% of the respondents were wearing high heels for 1-2 years and the same percentage was for 3-4 years. The mean of the sample was 2.5900 with a standard deviation of 1.16131.

Table 1 Since how long you are wearing high heels?

Years	Frequency	Percent	Mean	Std. Deviation
less than 1 year	49	24.5
1-2 years	45	22.5
3-4 years	45	22.5	2.5900	1.16131
5 years or more	61	30.5
Total	200	100.0

Question 2: How many days do you wear high heels per week?

Table 2 showed that most of the respondents (37%) used to wear high heels for 3 days a week while those who wear for 5 days a week were a second major part of the population (23.5%). 21.5% of respondents wearing it more than 5 days a week. 18% responded for 4 days a week. Mean was 2.2950 and the standard deviation was 1.17682.

Table 2 How many days do you wear high heels per week?

Days	Frequency	Percent	Mean	Std. Deviation
3 days	74	37.0
4 days	36	18.0
5 days	47	23.5	2.2950	1.17682
More	43	21.5
Total	200	100.0

Question 3: How long a day do you put your high heels on?

Table 3 showed that females wearing high heels for 6 hours a day were 28.5% of the total population. Those who wear it for more than 6 hours were on second with 27.5%. While the rest of them used to wear for 4 hours a day (23%) and 5 hours a day (21%).

Table 3 How long a day do you put your heels on?

Hours	Frequency	Percent	Mean	Std. Deviation
4 hours	46	23.0
5 hours	42	21.0
6 hours	57	28.5	2.6050	1.12038
More time	55	27.5
Total	200	100.0

Question 4: Height of your heels?

Table 4 showed that the height of the heel mostly wore was 1-2 inches (37%). 36.5% using 3-4 inches of heel height. While 17.5% wore 4-5 inches usually. 5-6 inches of heel height was used by only 9% of the total population. Mean and standard deviation were 1.9850 0.95358 respectively.

Table 4 Height of your heels?

Height of heel	Frequency	Percent	Mean	Std. Deviation
1-2 inches	74	37.0
3-4 inches	73	36.5
4-5 inches	35	17.5	1.9850	.95358
5-6 inches	18	9.0
Total	200	100.0

Question 5: Type of high heel you wear?

Table 5 showed that wedge heel was most favorite among ladies (41.5%). Secondly, platform heel was commonly used which comprises 20% of the total population. While the ankle strap and cone/pencil heel were 19.5% and 19% of the total population respectively. Mean of the sample was 2.1650 while the standard deviation was 1.16385.

Table 5 Type of high heel you wear?

Type of heel	Frequency	Percent	Mean	Std. Deviation
Wedge	83	41.5
Ankle strap	39	19.5
Platform heel	40	20.0	2.1650	1.16385
Cone/pencil heel	38	19.0
Total	200	100.0

Question 6: What is your personal perception of wearing high heel shoes?

Table 6 showed the frequency of responses regarding the personal perception of respondents about wearing high heels so most of them responded as a fashion (39.5%). 24.5% were wearing due to short height while 20% used to wear it to look professional. 16% counted for any other reason

Table 6 What is your personal perception of wearing high heel shoes?

Personal perception	Frequency	Percent	Mean	Std. Deviation
To look professional	40	20.0
Due to short height	49	24.5
As a fashion	79	39.5	2.5150	.98724
Any other	32	16.0
Total	200	100.0

. Question 7: Have you experienced any tightness in your calf/leg muscles?

Table 7 showed that how many of the respondents suffer from calf muscle tightness. 34.5% responded with mild tightness while the other 29% didn’t have it. 25.5% suffered moderate tightness in leg muscles. Severe tightness is complained only by 11% of respondents.

Table 7 Have you experienced any tightness in your calf/leg muscles?

Tightness	Frequency	Percent	Mean	Std. Deviation
None	58	29.0
Mild	69	34.5
Moderate	51	25.5	2.1850	.97752
Severe	22	11.0
Total	200	100.0

Question 8: Have you ever felt any hard skin below your big toe?

Table 8 showed that 37% of respondents had no hardening of skin below the big toe due to wearing high heels. 25.5% suffered from mild while 23% from moderate and 14.5% from severe hardening of skin below the big toe.

Table 8 Have you ever felt any hard skin below your big toe?

Hard skin	Frequency	Percent	Mean	Std. Deviation
None	74	37.0
Mild	51	25.5
Moderate	46	23.0	2.1500	1.07857
Severe	29	14.5
Total	200	100.0

Question 9: Have you had to use soft pads in your toe box/special shoes?

Table 9 showed that the majority of respondents (68.5%) never used a soft pad in their toe box. 22.5% used it most of the time while only 5% used it always. Only 4% of respondents used soft pads in the toe box sometimes.

Table 9 Have you had to use soft pads in your toe box/special shoes?

Soft pads	Frequency	Percent	Mean	Std. Deviation
Never	137	68.5
Sometimes	8	4.0
Most of times	45	22.5	1.6400	.99264
Always	10	5.0
Total	200	100.0

Question 10: Have you been able to walk on uneven ground?

Table 10 showed that the majority of respondents can easily walk on uneven surfaces wearing high heels.28.5% of the total population could walk with little difficulty. Respondents with moderate difficulty to walk are 19.5%. Only 7% responded with extreme difficulty in walking with high heels on uneven ground.

Table 12 Have you been able to walk on uneven ground?

Walk	Frequency	Percent	Mean	Std. Deviation
Yes easily	90	45.0
With little difficulty	57	28.5
With moderate difficulty	39	19.5	1.8850	.95727
With extreme difficulty	14	7.0
Total	200	100.0

Question 11: Do your feet hurt in heels?

Table 11 showed a majority of responses lie in the category of yes (86%) while the rest of them responded with no (14%).172 out of 200 complaints of foot pain while wearing high heels.

Table 11 Do your feet hurt in heels?

Feet hurt	Frequency	Percent	Mean	Std.  Deviation
Yes	172	86.0
No	28	14. 0	1.1400	.34786
Total	200	100.0

Question 12: Have you been troubled by pain in foot after putting of your heels?

Table 12 showed that respondents complaining of foot pain after putting off their heels were 63% of the total population while 37% of them responded with no pain. It means that more than half of the study population suffered from pain in foot after putting their high heels off.

Table 12 Have you been troubled by pain in foot after putting of your heels?

Pain	Frequency	Percent	Mean	Std. Deviation
Yes	126	63.0
No	74	37.0	1.3700	.48402
Total	200	100.0

Question 13: What are the areas of severe pain while wearing high heels?

Table 13 showed that 77% of the total population complained of pain in the forefoot while wearing high heels. 14% had no pain in any area of the foot. 6% complained of midfoot pain while only 5% responded to heel pain. The main concern of this study was well represented in this frequency distribution that foot pain experienced by females wearing high heels was most commonly located in the forefoot region with 77.5 of percentage.

Table 13 What are areas of severe pain while wearing high heels?

Areas of pain	Frequency	Percent	Mean	Std. Deviation
Forefoot	155	77.5
Middle of foot	12	6.0
Heel	5	2.5	1.5300	.69965
None	28	14.0
Total	200	100.0

Question 14: What is the intensity of your pain?

Table 14 showed the intensity of pain according to the visual analog scale. 54.5% had mild to moderate pain. Severe pain was complained by 29% of respondents. 12.5% responded with no pain and only 4% had the worst pain while wearing high heels.

Table 14 What is the intensity of your pain?

Intensity	Frequency	Percent	Mean	Std. Deviation
0 (No pain)	25	12.5
2-4 (Mild-moderate)	109	54.5
6-8 (Severe)	58	29.0	2.2450	0.71942
10 (Worst pain)	8	4.0
Total	200	100.0

Discussion

Few studies were available on this topic so it was a difficult task as limited literature was available. Almost every fourth women wear high heels for at least one day in the week. According to a study nearby 59% of females carry high-heel for 1-8 hours daily [10]. Wearing high heels causes changes in pressure distribution on foot [7]. Due to high-heel shoes, pressure, and bodyweight loading on forefoot increase and is decreased on the hind foot [9]. According to Cong et al. [4] high heels can cause increase loading on foot which in turn can lead to forefoot pain hallux valgus deformity and soft tissue problem on the plantar side of the foot. Broch et al. [3] stated that increasing the heel height the normal pressure distribution on foot was changed and forefoot was subjected to more constraint as compared to the heel of the foot. When we are wearing high heel shoes our feet assume such a position in which our heels are raised and elevated and our bodyweight shifts more to our footballs and toes (Tables 13 and 14).

After completing analysis, it came to a result with 77.5% females’ complaint of forefoot pain, while 6% of females’ complaint midfoot pain and 2.5% complaint of heel pain. While 14% responded no pain at all. So, it was concluded that forefoot was more common as compared to the other two regions of foot, hind foot, and heels. The reason behind might be that as compared to normal load distribution on the whole foot, more pressure is subjected to front of the foot. The forefoot is an anatomically delicate region as compared to the other two regions plus the increased pressure on it causes more pain in this region. The intensity of pain in Table 14 is interpreted as 4% female’s complaint of worst pain, 29% complaint of severe pain and 54.5% complaint of mild to moderate pain and 12.5% responded with no pain.

Conclusion

The finding of this study indicated that high heel shoes cause more pain in the forefoot as compared to other regions of foot because weight distribution is changed while wearing high heel shoes. The reason behind this suggests that high heel shoes changing the normal distribution of weight on the whole foot, forefoot region is more prone to bear pressure as compared to middle foot and heel.

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References

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