JOURNAL OF WOMEN’S HEALTH

Volume 15, Number 8, 2006

© Mary Ann Liebert, Inc.

Conversation with the Experts

Toward Optimal Health: D. Casey Kerrigan, M.D.,

Discusses the Impact of Footwear on the Progression of
Osteoarthritis in Women

JODI R. GODFREY, M.S., R.D.

D. Casey Kerrigan, M.D., is professor and chair of physical medicine and rehabilita-
tion and professor of sports medicine at the University of Virginia in Charlottesville,
Virginia. Her work on the impact of shoes on women’s health began when she was
an associate professor of physical medicine and director of the Center for Rehabilita-
tion Science at the Spaulding Rehabilitation Hospital and Harvard Medical School.

E IGHTY PERCENT OF THE

42 million Americans
suffering from arthritis have osteoarthritis, in
which joint cartilage and surrounding bone pro-
gressively degrade from wear and tear. Surgeons
perform 300,000 artificial knee replacements in
this country every year as a result of this condi-
tion. We can point to shoes as a major contribu-
tor to the high prevalence of knee osteoarthritis
in women, which is twice as high as in men. Os-
teoarthritis causes more disability in women
than
any other single disease. Women who do not yet
have osteoarthritis may be at risk, and this con-
dition typically produces a downward spiral in
overall health, leading to obesity,
deconditioning,
and ultimately death in a pattern similar to that
associated with hip fracture.
Recognizing that poorly fitting shoes can
cause
bunions, neuromas, corns, hammertoes, calluses,
ankle sprains, fractures, and other foot problems
and acknowledging that such foot problems are
much more common in women should be
enough
to elicit a greater groundswell of change in shoe
wear. Yet, even with clinical data, women are
still
hobbling around on high heels that put them at
8
D. Casey Kerrigan, M.D., has had the foresight
to recognize that the makeup of a shoe can have
significant consequences beyond the foot. In par-
ticular, her research demonstrates a strong asso-
ciation between improper shoes and osteoarthri-
tis. She agreed to discuss the implications of shoe
design on women’s health and the imperative
that women’s health practitioners must take an
active role in the prevention of osteoarthritis in
women.
Is foot health of sufficient concern that
primary care physicians should play a greater
role in evaluating women’s feet?
Let us consider the complexity of the human
foot, which consists of 26 bones and 33 joints
con- nected by muscles, tendons, and ligaments.
It is easy to predict that the foot is susceptible to
many stresses that can cause pain, inflammation,
or in- jury, causing limited movement and
mobility. Re- search focusing on shoe wear can
explain some of the gender discrepancy in the
prevalence of os- teoarthritis. The popularity of
high heels and nar- row toes makes it much
more likely that today’s women will develop
medical problems that be- gin in their feet and
move up to knees, hips, and other parts of the
body. With the increasing rate
CONVERSATION ABOUT WOMEN’S FOOTWEAR AND OSTEOARTHRITIS
of diabetes, which can lead to peripheral neu-
ropathy, there are many more women who face
special foot care problems that can and should
be
prevented by properly fitting shoes.
Can a woman’s shoes be hazardous to her
health?
Shoes play a critical and significant health role
not only in women who have osteoarthritis but
also in those who are at risk for it. The data on
the number of women who suffer from os-
teoarthritis are underrepresented in practice be-
cause the information tends to be based on the
number of knee replacement procedures or the
prescription volume for arthritis medications
rather than on the women whose function is im-
paired but who do not have a formal diagnosis
of overt osteoarthritis.
Walking on high heels puts abnormal stress on
both the front and the back of the knee. High
heels, whether they are thick or thin, can cause
problems for women’s knees, ankles, and feet.
Common shoe-related problems include ankle
sprains and breaks from rolling over on high-
heeled shoes. These are immediate problems, un-
like osteoarthritis of the knee, which develops af-
ter decades of wearing high heels.
Our understanding of the impact of shoe fash-
ion has evolved such that we now know that the
stiletto heel, which is presumed to be bad, is not
the only problem. In fact, the risk comes from
wearing any kind of heel—wide or narrow, high
or low—that changes the angle of the foot,
thereby placing a woman in danger of walking
in a way that puts added strain on the knee
joints. Wide-heeled shoes present a perception of
more stability, and they feel comfortable, so
women wear them all day long. Although they
are better for the feet than stiletto heels, wide-
heeled shoes are just as hard on the knees. It is
the height of the heel that appears to be the
problem; a mod- est 1-1/2 inch heel is sufficient
to increase the detri- mental forces on a woman’s
knee and the repet- itive stress on the knee joint.
Wearing wide-heeled shoes has an effect on
knee torque similar to that of stiletto-type heels.
Wearing wide-heeled shoes had a 30% greater ef-
fect on peak external knee flexor torque than
walking barefoot.2 Our findings suggest that
wide-heeled shoes cause abnormal forces across
the patellofemoral and medial compartments of
the knee, which are the typical anatomical sites
895
for degenerative joint changes.2 When it comes
to shoes, clinicians should bear in mind that it
takes a long time to feel the effects of knee
osteoarthri- tis, and once the patient does, it is
too late.
How does heel height promote osteoarthritis
of the knee?
Women naturally pronate more than men, and
the footwear industry has seized on this differ-
ence and attempted to market it by promoting a
high value in heel cushioning and arch support
in women’s footwear. Athletic shoes that attempt
to reduce pronation in this way are detrimental
in a lesser but similar way as that of high heels.
The idea has been to correct the pronation, but
blocking the natural function of this motion in-
creases the torque on the knee, producing nega-
tive consequences up the chain, ultimately re-
sulting in osteoarthritis.1
Walking in high heels puts abnormal stress on
both the front and the back of the knee. In one
study, walking with any heeled shoe increased
peak varus torque pressure on the knee by
22–26%.2 The health of the cartilage that forms
the padding between the bones in the knee is de-
pendent on the fluid in the knee. Cartilage ab-
sorbs the nutrients it needs from this liquid to re-
pair itself, but stress on the knee restricts
absorption of the fluid, and the cartilage begins
to dry and shred. Over time, it wears out, and
arthritis sets in. The development of osteoarthri-
tis is multifactorial, but knowing that high heels
can contribute should be enough to suggest pre-
ventive measures.
Why does the wider heel not provide a
sufficient strike surface to handle the gait
impact better than a stiletto heel, which is
difficult for most women to walk in?
The natural assumption is that a higher heel
pushes the foot forward, causing the biomechan-
ical problems that result in osteoarthritis. How-
ever, the foot is complex. Forward movement is
a multistage process in which the outside of the
foot essentially meets the ground at a 30-degree
angle, then the foot rolls over into the instep
(pronation) with the arch and 26 bones of the
foot absorbing the impact, and then the foot
needs to spring back. In effect, body weight is
shifted and is not fully met with a heel. The
forces of foot mo- tion are occurring in the
coronal plane, which must adjust to the torque
through the knee and
896 CONVERSATION ABOUT WOMEN’S FOOTWEAR AND OSTEOARTHRITIS
hips. If a high heel compromises this
complicated
process, an imbalance occurs in which the flow
across the coronal plane is adversely affected.
The
When the toe of the shoe is very narrow,
forcing the toes into a crowded space, does
this present an entirely separate set of
problems?
Although not studied clinically, as have shoe
heels, it seems quite apparent that the toebox
plays a role in the development of common foot
ailments, such as bunions, calluses, and the like,
as well as having a detrimental effect upward on
the body. Interestingly, we have not seen much
difference in the prevalence of osteoarthritis
whether the toebox fixes the toes into a space
that is cramped or roomy. The issue is more to
do with the rolling motion of the foot being
interrupted by the heel of the shoe.
Women have been sold on wearing shoes with
arch support. The arch support works against
normal body mechanics, however, similar to the
antipronating athletic shoe. We need to free the
arch to move naturally. Further, there is research
on military personnel, where feet with high
arches that do not pronate fully have a higher in-
cidence of stress fractures and other muscu-
loskeletal strains.
What might clinicians recommend to women
who are at risk for osteoarthritis?
There is no cure for osteoarthritis regardless of
the etiology, which is why it is so critical to focus
on preventing osteoarthritis. Once arthritis de-
velops in the knee, the risk for declining function
and overall health must be considered. Needless
to say, a woman with osteoarthritis should no
longer wear shoes with heels and should find
footwear that will augment the natural motion of
the foot. This type of shoe would provide suffi-
cient support and comfort to minimize the pain
and promote physical activity.
We also help manage osteoarthritis with per-
sonalized exercise prescriptions that promote
im- proved function, encourage weight loss, and
strengthen knee muscles without putting undue
force on the knee compartment. A physical med-
icine and rehabilitation physician will devise a
personalized program, which in combination
with the appropriate shoe insole is the best ther-
apeutic approach available at present.
Does the shape of a woman’s foot—wide or
narrow—make a difference in the
development of osteoarthritis?
This has not been studied, but it probably
does. It is certainly likely that genetics play a role
in different biomechanics. Traditionally, the
model for shoes is the male foot shape. However,
what research tells us is that compared with
having no insole, the 5-degree lateral-wedge
insole was as- sociated with an almost 6% overall
reduction in knee varus torque. The significant
difference be- tween the lateral-wedge and
control insoles demonstrated that the effect of
the wedge is the result of directly altering the
knee joint biome- chanics rather than being
merely the result of in- sole cushioning.
Moreover, the fact that there were no differences
in temporal parameters be- tween the conditions
supports the conclusion that the reduced
measured knee varus torque with the lateral
wedge was not merely the result of a slower
walking speed or stride length.
Having been immersed in this research, I be-
gan working on the design for an advanced wo-
man’s shoe, which features a patented yet
highly practical construction. We are about a
year away from selling the first female-friendly
shoe, which has taken 6 years of development
and design.
What is the profile of a good shoe?
The lateral-wedge insole is a conservative
treat- ment that can be useful at any point in
disease progression. It will help a newly
diagnosed pa- tient as well as someone who has
had os- teoarthritis of the knee for years. Of
equal con- cern is another common shoe feature:
the arch support, which ostensibly promotes
comfort but inhibits the natural functioning of
the foot.
Eventually, most women will develop arthritic
changes in the medial part of the knee. Clinicians
will want to consider the importance of promot-
ing the functional aspects of walking: efficiency,
comfort, risk of falling, and risk of biomechani-
cal injury. To minimize the deleterious effects of
shoes and the associated increased risk of os-
teoarthritis, physicians can prescribe a shoe that
has little arch support, is essentially flat (with
minimal padding in the heel) and promotes the
natural striking motion of the foot. By recom-
mending shoes that have wedged insoles, clini-
cians may be able to slow the progression of
knee osteoarthritis and the related pain.
CONVERSATION ABOUT WOMEN’S FOOTWEAR AND OSTEOARTHRITIS 897

REFERENCES Kerrigan DC, Johansson JL, Bryant MG, Boxer

JA,
1. Kerrigan DC, Lelas JL, Goggins J, Merriman GJ, Kap- Della Croce U, Riley PO. Moderate-heeled shoes
lan RJ, Felson DT. Effectiveness of a lateral-wedge in- and knee joint torques relevant to the develop-
sole on knee varus torque in patients with knee os-
ment and progression of knee osteoarthritis.
teoarthritis. Arch Phys Med Rehabil 2002;83:889.
2. Kerrigan DC, Lelas JL, Karvosky ME. Women’s shoes
Arch
and knee osteoarthritis. Lancet 2001;357:1097. Address correspondence to:
Jodi R. Godfrey, M.S., R.D.
Contributing
ADDITIONAL RESOURCES Editor
Journal of Women’s Health
Kerrigan DC, Todd MK, Riley PO. Knee os- 31 Macopin Avenue
teoarthritis and high-heeled shoes. Lancet Upper Montclair, NJ 07043
1998;351:1399. E-mail: jodigodfrey@comcast.net