Wearing high-heeled shoes increases the foot arch angle inducing measurable changes in the musculoskeletal system

Abstract

BACKGROUND AND OBJECTIVE:

The study determined the effects of females wearing high-heeled shoes on the lower extremity musculoskeletal system and somatometry.

METHODS:

The study was carried out with 136 females between 18 and 45 years old. The first group consisted of 66 females wearing 5 cm or higher high-heeled shoes, at least 5 hours a day, three days a week, and at least one year. The second group consisted of 70 females wearing shoes with heel height less than 5 cm for at least one year.

RESULTS:

Differences in length parameters may result from the narrow and pointed toe of the high-heeled shoe. These shoes distribute the pressure on the caput ossis metatarsi I and compress the foot in this area. Differences in anthropometric measurements show that females wearing high-heeled shoes have more slender and smaller foot structure.

CONCLUSION:

These findings show that regular wearing of high-heeled shoes causes changes via the increased foot arch structure. These alterations result from regional, racial, gender, heel height, shoe type (shape), and shoe habits.

Keywords

Musculoskeletal system high heeled shoes foot print analysis

1. Introduction

The musculoskeletal system is an important part of the movement system and consists of bone, joints, and ligamentous tissue [1]. The lower extremities play a significant role in posture and walking [2]. The foot contacts the floor with the caput ossis metatarsi I-V on the anterior side and the tuber calcanei on the posterior side [3]. Foot arches, which are formed by osseous, tendons, muscles, and ligamentous structures, flexibly transmit body weight to the floor. The arch allows adaptation of the foot to both weight and contact surface alterations [2, 4, 5]. Foot arch structure and function depend on factors including bony structure, ligament stability, shoe, age, gender, and race, which affect the arcus pedis longitudinalis pars medialis [4, 6, 7].

Using high-heeled shoes (HHS) changes the structure and function of body. HHS have important effects on balance, walking, posture, and foot stability [8]. Moreover, HHS lead to alterations including stiffness and reduction in the Achilles Tendon (AT), reduction in ankle joint range of motion (ROM), and shortness in calf muscles [8]. HHS lead to a decrease in walking speed and increase in the ROM of the plantar flexion and knee flexion [9]. Shoes have evolved from the practical origin of protecting the foot from various traumas and providing connection between the body and surface to the grandiose heights [10, 11, 12]. Anthropometry, which includes length, circumference, and width, gives information about body size and structure. Anthropometric data shows differences in lower extremities according to race, gender, culture and socio-economics and ethnic group [13].

This study determined with objective methods how the use of HHS affects the lower extremity musculoskeletal system and somatometric relationships between the lower extremity anthropometric measurements in females wearing HHS.

2. Materials and methods

One hundred and thirty-six females between 18 and 45 years old participated in the study. The first group consisted of 66 females wearing HHS 5 cm or more for at least one year, three times a week, and 5 hours a day. The second group consisted of 70 females wearing shoes having a heel height less than 5 cm for at least one year. Inclusion criteria for this study were

(1)
absence of any history of trauma, serious pathology, and infection,
(2)
absence of fracture and previous lower extremity or vertebral column surgery,
(3)
absence of any neuromuscular or musculoskeletal disorder,
(4)
body mass index (BMI) $<$ 30.

All test procedures were approved by the Ethics Committee of Cukurova University Institutional Board. All subjects provided informed consent. Demographic variables (age, weight, height, and BMI) were recorded. BMI was calculated using the standard (kg/m ${}^{2}$ ) formula [14]. Length, width, and circumference measurements of the lower extremity were taken to detect changes in bony structure and compare with other extremities using antropometrics (Anthropometer 01290, Lafayette Instruments), a digital sliding caliper (Mitutoyo) that is capable of measuring to the nearest 0.01 mm, and an inflexible tape measure from reference points. Moreover, flexibility test measurements (the length of hamstring muscle, trunk flexion, hyperextension etc.) were performed. Furthermore, footprint analyses were evaluated in a dynamic position on a measurement platform. Chippaux Smirak Arch Index (CSAI) and Staheli Arch Index (SAI) were calculated from these measurements.

These calculations were as follows

(1)
CSAI $>$ 0.45 $=$ Pes planus (flatfoot)
(2)
0.1 $<$ CSAI $<$ 0.29 $=$ Normal arch
(3)
CSAI $=$ 0 $=$ Pes cavus (high arch)
(4)
SAI $>$ 0.6 $=$ Low arch
(5)
0.3 $<$ SAI $<$ 0.59 $=$ normal arch.
(6)
0 $<$ SAI $<$ 0.29 $=$ high longitudinal arch [15].

Reference points and definitions of the measurement parameters are mentioned below.

Lower extremity length (LEL) is the distance between the trochanter major (TM) and malleolus medialis (MM). Thigh length (TL) is the distance from the patella margo proximalis to the midpoint of the ligamentum inguinale. Leg length (LL) measurement is taken from the tuberositas tibiae to MM [13]. Forefoot length (FFL: sphyrion-acropodion) measurement is taken from the margo anterior of the MM to the most distal point of the longest toe [17]. Truncated foot (TF) is the distance from the pternion to the head of the first metatarsal bone [18]. Caput ossis metatarsi-I height (CMH ${}_{1}$ ) is the vertical distance from the floor to the upper surface of the first metatarsal head [19, 20]. Caput ossis metatarsi-V height (CMH ${}_{v}$ ) is the vertical distance from the floor to the upper region of the fifth metatarsal head [20]. The ankle height is made from two points [21, 22]: Malleolus lateralis height (MLH) is the distance from the floor to the malleolus lateralis (ML). Malleolus medialis height (MMH) is the distance from the floor to the MM. The navicular height (NH) measurement is taken from the floor to the most prominent point of the navicular bone [22]. Foot metatarsal circumference is the perimeter measurement from the most significant point of the medial region of the first metatarsal head to the most prominent point of the lateral region of the fifth metatarsal head [19, 23]. Heel circumference is the perimeter measurement made diagonally from the base of the heel to the top of the foot where it connects to ankle. Instep circumference is from the medial arch gap of the foot to the highest point of the foot dorsum [23]. Thigh circumference measurements (TCM ${}_{1}$ -TMC ${}_{2}$ ) are made two ways. For TCM ${}_{1}$ , the circumference measurement is taken 15 cm superior of the patella. For TCM ${}_{2}$ , the reference point is the most bulging point of the thigh muscles. For leg circumference measurements (LCM ${}_{1}$ -LCM ${}_{2}$ ) two reference points are used. For LCM ${}_{1}$ , the circumference measurement is made 15 cm above the MM. For LCM ${}_{2}$ , the measurement is performed from the most bulging of calf muscles [13, 20]. Ankle circumference [13] is the thinnest point of ankle (slightly over MM and ML). Foot metatarsal width is the distance in between the most prominent point of the medial region of the first metatarsal head and the fifth metatarsal head lateral region [21, 23, 24, 25]. Heel width measurement is the distance between the most apparent points of the inner and outer side of the heel [24]. The biiliac diameter measurement is taken from the widest place of the pelvis between the outer edges of the crista iliaca. The caliper’s levers are held at an angle of 45 degrees. The bitrochanteric diameter measurement is performed from the greater trochanter of femora on the right and left sides [13]. The bimalleolar width is the distance between the most medially protruding point on the MM and the most protruding point on the ML [13]. For the 6-meter walking time test, were instructed to walk the specified distance [26]. For longitudinal arch angle (LAA) measurement, a line is drawn from the head of the first metatarsal bone to the navicular tuberosity and, from the navicular tuberosity to the center of the MM. The angle between the lines is measured as degrees [27]. For foot shape (calculation of foot index – FI) measurement, the formulas are as follows: Slender foot FI ${}^{}$ $<$ FI – SD (Standard deviation); Standard type foot FI – SD $<$ FI ${}^{}$ $<$ FI $+$ SD; Broad type FI ${}^{}$ $>$ FI $+$ SD [28]. In this calculation, while “FI ${}^{}$ ” expresses the FI mean value of one subject, FI defines the mean foot index of all participants. Moreover, if a subject’s foot index (FI ${}^{}$ ) is higher than all subjects’ foot indexes (FI $+$ SD), the foot shape type is accepted as broad. If FI ${}^{}$ is lower than FI-SD, the foot shape is accepted as slender. In the sit and reach test, the subject sits on the floor. The subject’s feet and legs are stretched out towards the box straight ahead. The subject reaches with hands and arms forward as far as she can on the box and the distance is recorded [13]. In the trunk flexion flexibility test, the position is the same as the sit and reach test (Fig. 1). During measurement, a standard rolled towel is placed under the knee and knees are in a slight flexion position. The subject reaches forward as far as possible and this distance is recorded [13]. In the trunk hyperextension flexibility test, the subject stands, facing the wall with arms at the side, and trunk, hip, and chest adjacent to wall. First, the distance between the wall and incisura jugularis is marked. Then, the subject bends the trunk posteriorly as far as possible without drifting the hips away from the wall. The end point is marked. The distance between the end and first point is rmeasured with a tape measure [1, 13]. In the trunk lateral flexion flexibility test, the measurement is performed while standing with, feet opened slightly and, arms at sides. First, the most distal point of the right hand middle finger is marked on the thigh outer surface. Then, the subject bends the trunk laterally as far as possible. This end point is marked. It is recorded as the distance between end points in cm [1, 13]. The ankle gastrocnemius flexibility test is performed while standing one meter from the wall. The face looks at the corner and arms are placed in a reverse T position, with forearms placed against the wall on both sides of the corner. The distance from the wall to the incisura jugularis is recorded. Then, the subject leans forward as far as possible while maintaining the vertebral column, and hip and knees extension positions. The feet should remain in contact with the floor. The distance from the wall to the incisura jugularis is recorded [13] and the second measurement value is subtracted from the first value to obtain the final recorded score.

Figure 1.
Trunk flexion flexibility test.

SPSS version 21 software package program was used for all analysis. Dependent variables demonstrated either normal or non-normal distribution. A parametric test (Independent Samples T Test) or non-parametric test (Mann Whitney U Test) was applied according to the Kolmogorov-Smirnov test results. Moreover, the Chi square test and Spearman Pearson Correlation analysis were used. Significance was set at $p<$ 0.05 [16].

Table 1
Foot length measurements and 6-m walking test in females wearing high-heeled shoes (HHS) and non- high-heeled shoes (NHHS)

Parameters (cm) Females wearing HHS Females wearing NHHS $p$

Min. Max. Mean $\pm$ SD Min. Max. Mean $\pm$ SD

Foot length (right) ${}^{\pm\pm}$ 21.90 26.60 24.26 $\pm$ 1.03 22.10 27.00 24.36 $\pm$ 1.10 0.606

Foot length (left) ${}^{\pm\pm}$ 22.20 26.60 24.22 $\pm$ 0.98 22.20 26.90 24.25 $\pm$ 1.07 0.889

Truncated foot length (right) ${}^{\pm\pm}$ 16.00 19.50 17.83 $\pm$ 0.83 16.00 20.10 17.95 $\pm$ 0.90 0.424

Truncated foot length (left) ${}^{\pm\pm}$ 16.15 19.30 17.72 $\pm$ 0.77 16.00 19.90 17.91 $\pm$ 0.91 0.201

Forefoot length (right) ${}^{\pm\pm}$ 15.20 19.50 17.49 $\pm$ 1.05 15.80 19.50 17.56 $\pm$ 0.84 0.678

Forefoot length (left) ${}^{\pm}$ 14.50 19.15 17.26 $\pm$ 1.06 16.00 19.30 17.58 $\pm$ 0.76 0.048

LAA degree (right) ${}^{\pm\pm}$ 156.00 182.00 173.81 $\pm$ 6.92 140.00 170.00 152.44 $\pm$ 7.26 $<$ 0.001

LAA degree (left) ${}^{\pm}$ 159.00 187.5 174.84 $\pm$ 6.52 133.00 171.00 150.84 $\pm$ 7.49 $<$ 0.001

P ${}_{1}$ length (right) ${}^{\pm\pm}$ 5.10 7.35 6.41 $\pm$ 0.57 5.10 7.30 6.37 $\pm$ 0.54 0.568

P ${}_{1}$ length (left) ${}^{\pm}$ 5.00 7.80 6.47 $\pm$ 0.58 5.10 7.20 6.29 $\pm$ 0.49 0.026

P ${}_{2}$ length (right) ${}^{\pm}$ 4.50 7.70 5.98 $\pm$ 0.77 3.50 7.00 5.70 $\pm$ 0.72 0.041

P ${}_{2}$ length (left) ${}^{\pm\pm}$ 4.40 7.65 6.06 $\pm$ 0.78 4.35 6.80 5.64 $\pm$ 0.62 0.010

P ${}_{5}$ length (right) ${}^{\pm\pm}$ 3.90 6.00 4.72 $\pm$ 0.49 3.40 5.60 4.81 $\pm$ 0.46 0.370

P ${}_{5}$ length (left) ${}^{\pm}$ 3.00 6.00 4.70 $\pm$ 0.51 3.30 5.75 4.68 $\pm$ 0.44 0.593

Feiss line length (right) ${}^{\pm}$ 10.00 14.00 11.99 $\pm$ 0.82 10.30 13.70 11.98 $\pm$ 0.76 0.838

Feiss line length (left) ${}^{\pm}$ 10.00 13.40 11.81 $\pm$ 0.81 10.50 13.40 12.04 $\pm$ 0.60 0.126

6-m walking test (seconds) ${}^{\pm\pm}$ 4.00 7.5 5.62 $\pm$ 0.83 4.00 10.00 6.80 $\pm$ 1.11 $<$ 0.001

${}^{\pm}$ Mann Whitney U Test, ${}^{\pm\pm}$ Independent Samples T Test. P ${}_{1}$ : first phalanx; P ${}_{2}$ : second phalanx; P ${}_{5}$ : Fifth phalanx.

3. Results

The records of 136 females (70 females who were wearing NHHS, and 66 females who were wearing HHS) were assessed. The mean age, height, weight and body mass index (BMI) values of the HHS group were 33.41 $\pm$ 7.02 years, 163.06 $\pm$ 6.41 cm, 58.51 $\pm$ 7.65 kg and 22.18 $\pm$ 3.04 kg/m ${}^{2}$ , respectively. In the NHHS group, these values were 30.50 $\pm$ 6.74 years, 163.63 $\pm$ 5.60 cm, 58.29 $\pm$ 6.52 kg, and 21.80 $\pm$ 2.25 kg/m ${}^{2}$ , respectively. There were no significant differences in all parameters excluding age ( $p<$ 0.05). While 51.47% of the subjects were using shoe heel heights less than 5 cm, 48.53% subjects worn HHS 5 cm or more in this study. Moreover, the mean values of heel height (HH), shoe length, and shoe width of females wearing HHS were 8.87 $\pm$ 1.82 cm, 22.97 $\pm$ 1.99 cm, and 7.93 $\pm$ 0.44 cm, respectively. The same values were 2.76 $\pm$ 0.77 cm, 24.66 $\pm$ 1.45 cm, and 8.61 $\pm$ 0.45 cm in NHHS, respectively. We found significant differences in the means of these values betwen the two groups ( $p<$ 0.001). Additionally, the mean value of standing time with HHS was 10.42 years. On the right and left side, the mean ratio values of standard, broad and slender foot were 80.30%–71.21%, 9.09%–7.58%, and 10.61%–21.21% in females wearing HHS, respectively. The same parameters were 71.43%–67.14%, 14.285%–14.29%, and 14.285%–18.57% in females wearing NHHS, respectively. There were no significant difference between the two groups (right; $p=$ 0.979; left; $p=$ 0.445).

Table 2
Foot anthropometric and circumference measurements in females wearing high-heeled shoes (HHS) and non-HHS (NHHS)

Parameters	Females wearing HHS			Females wearing NHHS			$p$
	Min.	Max.	Mean $\pm$ SD	Min.	Max.	Mean $\pm$ SD
MMH (right) ${}^{\pm\pm}$	5.20	8.10	6.46 $\pm$ 0.63	5.00	7.50	6.20 $\pm$ 0.66	0.023
MMH (left) ${}^{\pm}$	5.40	8.10	6.42 $\pm$ 0.59	5.00	7.50	6.22 $\pm$ 0.62	0.090
MLH (right) ${}^{\pm}$	4.60	7.25	5.59 $\pm$ 0.58	4.00	6.50	5.24 $\pm$ 0.57	$<$ 0.001
MLH (left) ${}^{\pm}$	4.50	7.10	5.56 $\pm$ 0.52	4.00	6.50	5.29 $\pm$ 0.58	0.004
NH (right) ${}^{\pm}$	4.00	6.00	4.80 $\pm$ 0.53	2.40	4.50	3.57 $\pm$ 0.45	$<$ 0.001
NH (left) ${}^{\pm}$	4.00	6.00	4.77 $\pm$ 0.48	2.85	4.50	3.57 $\pm$ 0.40	$<$ 0.001
Feiss line-os naviculare distance (right) ${}^{\pm}$	$-$ 1.05	0.40	$-$ 0.26 $\pm$ 0.36	$-$ 2.50	$-$ 0.20	$-$ 1.30 $\pm$ 0.43	$<$ 0.001
Feiss line-os naviculare distance (left) ${}^{\pm}$	$-$ 1.20	0.40	$-$ 0.21 $\pm$ 0.31	$-$ 2.35	$-$ 0.40	$-$ 1.37 $\pm$ 0.37	$<$ 0.001
Feiss line-floor distance (right) ${}^{\pm}$	4.00	6.00	5.06 $\pm$ 0.45	4.05	5.50	4.88 $\pm$ 0.32	0.008
Feiss line-floor distance (left) ${}^{\pm}$	4.00	6.00	4.99 $\pm$ 0.45	4.40	5.80	4.95 $\pm$ 0.32	0.353
CMH ${}_{1}$ (right) ${}^{\pm}$	2.60	3.80	3.21 $\pm$ 0.28	1.80	3.90	2.96 $\pm$ 0.64	$<$ 0.001
CMH ${}_{I}$ (left) ${}^{\pm}$	2.60	3.80	3.22 $\pm$ 0.26	1.80	3.75	2.96 $\pm$ 0.32	$<$ 0.001
CMH ${}_{V}$ (right) ${}^{\pm\pm}$	1.70	2.70	2.16 $\pm$ 0.23	1.20	3.00	1.94 $\pm$ 0.35	$<$ 0.001
CMH ${}_{V}$ (left) ${}^{\pm}$	1.70	2.70	2.21 $\pm$ 0.22	1.30	2.80	1.96 $\pm$ 0.32	$<$ 0.001
Foot metatarsal circumference (right) ${}^{\pm}$	19.80	24.50	21.88 $\pm$ 1.09	19.70	24.50	22.27 $\pm$ 0.99	0.022
Foot metatarsal circumference (left) ${}^{\pm}$	19.50	23.50	21.78 $\pm$ 1.09	19.30	24.10	22.29 $\pm$ 0.95	0.002
Foot instep circumference (right) ${}^{\pm}$	21.30	26.50	24.01 $\pm$ 1.13	21.40	27.00	24.13 $\pm$ 1.33	0.891
Foot instep circumference (left) ${}^{\pm\pm}$	21.00	26.00	24.00 $\pm$ 1.12	21.80	27.50	24.25 $\pm$ 1.24	0.221
Heel circumference (right) ${}^{\pm}$	24.20	31.50	28.29 $\pm$ 1.46	24.90	33.00	29.76 $\pm$ 1.41	0.020
Heel circumference (left) ${}^{\pm}$	24.00	31.00	29.09 $\pm$ 1.41	25.00	33.50	29.77 $\pm$ 1.35	0.050
Ankle circumference (right) ${}^{\pm\pm}$	18.00	24.00	21.19 $\pm$ 1.39	19.10	25.00	21.56 $\pm$ 1.34	0.119
Ankle circumference (left) ${}^{\pm}$	18.00	24.50	21.33 $\pm$ 1.32	19.00	26.00	21.60 $\pm$ 1.32	0.497
Lower limb circumference measurement I (right) ${}^{\pm\pm}$	23.80	35.00	29.62 $\pm$ 2.66	25.30	37.00	30.43 $\pm$ 2.44	0.068
Lower limb circumference measurement I (left) ${}^{\pm\pm}$	22.80	35.00	29.94 $\pm$ 2.83	25.00	37.00	30.41 $\pm$ 2.53	0.303
Lower limb circumference measurement II (right) ${}^{\pm\pm}$	30.50	39.50	35.20 $\pm$ 2.23	29.00	42.00	35.16 $\pm$ 2.64	0.922
Lower limb circumference measurement II (left) ${}^{\pm}$	30.50	39.50	35.33 $\pm$ 2.24	29.00	42.30	35.19 $\pm$ 2.59	0.340
Thigh circumference measurement I (right) ${}^{\pm\pm}$	34.50	57.00	48.10 $\pm$ 4.18	38.00	59.00	46.20 $\pm$ 4.13	0.009
Thigh circumference measurement I (left) ${}^{\pm\pm}$	34.00	57.80	48.06 $\pm$ 4.35	38.50	57.10	46.16 $\pm$ 4.03	0.010
Thigh circumference measurement I (right) ${}^{\pm\pm}$	35.50	67.50	57.46 $\pm$ 5.52	46.00	68.50	54.36 $\pm$ 4.75	0.001
Thigh circumference measurement II (left) ${}^{\pm}$	42.50	69.00	58.12 $\pm$ 4.94	45.90	67.00	54.42 $\pm$ 4.67	$<$ 0.001

${}^{\pm}$ Mann Whitney U Test, ${}^{\pm\pm}$ Independent Samples T Test.

Table 3

Lower extremity width (breadth) and length measurements in females wearing high-heeled shoes (HHS) and non-HHS (NHHS)

Parameters (cm)	Females wearing HHS			Females wearing NHHS			$p$
	Min.	Max.	Mean $\pm$ SD	Min.	Max.	Mean $\pm$ SD
Foot metatarsal width (FMW-right) ${}^{\pm\pm}$	7.45	10.00	8.73 $\pm$ 0.54	7.80	9.70	8.79 $\pm$ 0.44	0.468
Foot metatarsal width (FMW-left) ${}^{\pm}$	7.65	10.10	8.74 $\pm$ 0.51	7.60	9.85	8.81 $\pm$ 0.44	0.301
Ankle width (right) ${}^{\pm}$	5.00	6.90	6.10 $\pm$ 0.38	4.90	6.82	6.09 $\pm$ 0.41	0.929
Ankle width (left) ${}^{\pm}$	5.00	7.10	6.14 $\pm$ 0.39	5.25	6.80	6.10 $\pm$ 0.36	0.641
Foot heel width (right) ${}^{\pm}$	4.00	6.05	5.20 $\pm$ 0.36	4.30	6.40	5.38 $\pm$ 0.49	0.019
Foot heel width (left) ${}^{\pm\pm}$	4.00	6.15	5.25 $\pm$ 0.37	4.10	6.50	5.41 $\pm$ 0.47	0.019
Knee joint width (right) ${}^{\pm\pm}$	7.75	12.00	9.80 $\pm$ 0.83	7.60	10.70	8.91 $\pm$ 0.71	$<$ 0.001
Knee joint width (left) ${}^{\pm\pm}$	7.70	11.70	9.82 $\pm$ 0.83	7.45	11.00	8.86 $\pm$ 0.71	$<$ 0.001
Bitrochanteric width ${}^{\pm}$	23.7	37.50	33.99 $\pm$ 2.02	23.0	39.50	34.26 $\pm$ 2.63	0.454
Biiliac width ${}^{\pm}$	19.5	36.00	24.05 $\pm$ 2.26	20.50	35.20	24.96 $\pm$ 2.59	0.030
Calf muscle height (right) ${}^{\pm}$	22.50	33.00	26.67 $\pm$ 2.15	20.00	31.50	25.64 $\pm$ 2.08	0.005
Calf muscle height (left) ${}^{\pm}$	22.50	33.00	26.84 $\pm$ 2.10	21.50	31.00	25.63 $\pm$ 1.92	0.001
Lower limb length (LL-right) ${}^{\pm}$	27.00	36.50	31.20 $\pm$ 2.00	26.50	36.00	31.38 $\pm$ 1.91	0.474
Lower limb length (LL-left) ${}^{\pm}$	27.50	37.00	31.17 $\pm$ 2.01	26.00	35.50	31.45 $\pm$ 1.81	0.271
Thigh length (TL-right) ${}^{\pm}$	30.00	42.50	35.51 $\pm$ 2.46	31.00	42.50	36.49 $\pm$ 2.27	0.012
Thigh length (TL-left) ${}^{\pm}$	29.50	42.50	35.42 $\pm$ 2.52	30.90	42.20	36.53 $\pm$ 2.29	0.003
Distance trochanter major and malleolus medialis (right) ${}^{\pm\pm}$	66.00	84.50	73.58 $\pm$ 4.16	64.50	83.50	74.43 $\pm$ 4.22	0.237
Distance trochanter major and malleolus medialis (left) ${}^{\pm\pm}$	66.00	85.00	73.52 $\pm$ 4.10	64.50	83.50	74.45 $\pm$ 4.35	0.205

${}^{\pm}$ Mann Whitney U test, ${}^{\pm\pm}$ Independent Samples T test.

Table 4

Lower extremity circumference index and flexibility measurements in females wearing high-heeled shoes (HHS) and non-HHS (NHHS)

Parameters	Female wearing HHS		Female wearing NHHS		$p$
	Mean $\pm$ SD		Mean $\pm$ SD
LCM ${}_{1}$ /TCM ${}_{1}$ (right) ${}^{\pm}$	61.77	$\pm$ 5.84	65.95	$\pm$ 4.56	$<$ 0.001
LCM ${}_{1}$ /TCM ${}_{1}$ (left) $\pm$	62.47	$\pm$ 5.93	66.06	$\pm$ 4.61	$<$ 0.001
LCM ${}_{2}$ /TCM ${}_{2}$ (right) ${}^{\pm\pm}$	60.45	$\pm$ 3.56	64.98	$\pm$ 4.45	$<$ 0.001
LCM ${}_{2}$ /TCM ${}_{2}$ (left) ${}^{\pm}$	60.47	$\pm$ 3.35	64.94	$\pm$ 4.13	$<$ 0.001
Sit and reach test (right) ${}^{\pm}$	$-$ 2.90	$\pm$ 8.52	$-$ 1.34	$\pm$ 6.45	0.194
Sit and reach test (left) ${}^{\pm}$	$-$ 3.31	$\pm$ 9.11	$-$ 1.33	$\pm$ 6.32	0.114
Trunk flexion flexibility test (right) ${}^{\pm}$	1.89	$\pm$ 8.35	2.28	$\pm$ 5.67	0.550
Trunk flexion flexibility test (left) ${}^{\pm}$	1.57	$\pm$ 8.48	2.10	$\pm$ 5.70	0.693
Ankle and gastrocnemius muscle flexibility test (right) ${}^{\pm\pm}$	25.52	$\pm$ 5.43	28.86	$\pm$ 6.00	0.001
Trunk hyperextension flexibility ${}^{\pm}$	13.60	$\pm$ 3.52	16.95	$\pm$ 5.11	$<$ 0.001
Trunk lateral flexion (right) ${}^{\pm}$	18.35	$\pm$ 4.49	17.15	$\pm$ 3.98	0.131
Trunk lateral flexion (left) ${}^{\pm}$	18.35	$\pm$ 4.70	16.94	$\pm$ 3.91	0.078

${}^{\pm}$ Mann Whitney U test, ${}^{\pm\pm}$ Independent Samples T test. LCM: lower limb circumference measurement; TCM: Thigh circumference measurements.

Table 5

The Staheli Arch Index (SAI) and Chippaux-Smirak Arch Index (CSAI) values for females wearing high-heeled shoes and non-HHS (NHHS)

Arch Index	Females wearing HHS	Females wearing NHHS	$p$
	Mean $\pm$ Standard deviation	Mean $\pm$ Standard deviation
Staheli Arch Index (SAI-right) ${}^{\pm}$	0.52 $\pm$ 0.09	0.69 $\pm$ 0.11	$<$ 0.001
Staheli Arch Index (SAI-left) ${}^{\pm\pm}$	0.52 $\pm$ 0.08	0.67 $\pm$ 0.13	$<$ 0.001
Chippaux-Smirak Arch Index (CSAI-right) ${}^{\pm\pm}$	0.33 $\pm$ 0.06	0.42 $\pm$ 0.07	$<$ 0.001
Chippaux-Smirak Arch Index (CSAI-left) ${}^{\pm\pm}$	0.34 $\pm$ 0.07	0.41 $\pm$ 0.08	$<$ 0.001

${}^{\pm}$ Mann Whitney U Test, ${}^{\pm\pm}$ Independent Samples T test.

The comparison of the 6-m walking test and foot length measurements are shown in Table 1. There were significant differences between the two groups in MM height (right), ML height, NH, the distance from the feiss line to os naviculare, feiss line to floor distance (right), caput ossis metatarsi ${}_{1-V}$ heights, foot metatarsal circumference, heel circumference (right), and thigh circumference measurements ${}_{1-2}$ ( $p<$ 0.05, Table 2). Table 3 shows lower extremity width (breadth) and length measurements, whereas Table 4 shows lower extremity circumference index and flexibility test measurements. In addition, there were significant differences in mean values of SAI and CSAI between the two groups (Table 5).

Correlation analysis for NH (right) and NH (left), NH (right) and HH, NH (left) and HH, NH (right) and CMH ${}_{I}$ (right), NH (left) and CMH ${}_{I}$ (left), NH (right) and longitudinal arch angle (LAA-right), NH (left) and LAA (left), and CMH ${}_{I}$ (right) and CMH ${}_{I}$ (left) revealed the values of 0.951 (very high correlation), 0.730 (high correlation), 0.759 (high correlation), 0.364 (weak correlation), 0.475 (weak correlation), 0.842 (high correlation), 0.807 (high correlation), and 0.888 (high correlation), respectively. Furthermore, correlation values of foot length (FL-right) and FL (left), FL (right) and TFL (right), FL (right) and FFL (right), FL (left) and TFL (left), FL (left) and FFL (left), TFL (right) and TFL (left), TFL (right) and FFL (right), TFL (left) and FFL (left), and FFL (right) and FFL (left) were 0.950 (very high correlation), 0.844 (high correlation), 0.753 (high correlation), 0.819 (high correlation), 0.671 (moderate correlation), 0.823 (high correlation), 0.571 (moderate correlation), 0.482 (weak correlation) and 0.765 (high correlation), respectively. A significant difference was found between females wearing and non-wearing HHS for SAI and CSAI parameters (Table 5). Correlation analysis for HH and SAI (right), HH and SAI (left), HH and CSAI (right), HH and CSAI (left), NH (right) and SAI (right), NH (left) and SAI (left), NH (right) and CSAI (right), NH (left) and CSAI (left), SAI (right) and CSAI (right), SAI (left) and CSAI (left), SAI (right) and SAI (left) and CSAI (right) and CSAI (left) were $-$ 0.650 (negative moderate correlation), $-$ 0.545 (negative moderate correlation), $-$ 0.574 (negative moderate correlation), $-$ 0.477 (negative weak correlation), $-$ 0.577 (negative moderate correlation), $-$ 0.486 (negative weak correlation), $-$ 0.477 (negative weak correlation), $-$ 0.341 (negative weak correlation), 0.912 (very high correlation), 0.870 (high correlation), 0.885 (high correlation), and 0.859 (high correlation), respectively. Correlation analysis measurements including ankle gastrocnemius muscle flexibility (m ${}_{GC}$ ) and plantar flexion range of motion (PF ${}_{\textit{ROM}}$ ) (right), m ${}_{GC}$ flexibility and PF ${}_{\textit{ROM}}$ (left), m ${}_{GC}$ flexibility and HH, PF ${}_{\textit{ROM}}$ (right) and HH were $-$ 0.808 (negative high correlation), $-$ 0.674 (negative moderate correlation), $-$ 0.525 (negative moderate correlation) and 0.553 (moderate correlation), respectively.

Linear regression analysis was used to describe the statistical relationship between heel height, foot dorsum height, MMH, and PF ${}_{\textit{ROM}}$ variables, and right and left side results explained 76.1% and 71.7% of NH alteration, respectively. When we examined these results, strong effect from heel height ( $\beta=$ 0.593, $p<$ 0.001), foot dorsum height ( $\beta=$ 0.264, $p<$ 0.001), MM height ( $\beta=$ 0.175, $p=$ 0.019), and PF ${}_{\textit{ROM}}$ ( $\beta=$ 0.123, $p=$ 0.031) on the right side was determined. In addition, on the left side there was a strong effect from heel height ( $\beta=$ 0.638, $p<$ 0.001) and foot dorsum height ( $\beta=$ 0.161, $p=$ 0.020). The relationship between longitudinal arch angle (LAA), caput ossis metatarsi-I and NH variables explained 80.1% and 78% of NH alteration on the right and left sides, respectively. When we investigated these results, there were strong effect for LAA ( $\beta=$ 0.742, $p<$ 0.001) and CMH ${}_{I}$ ( $\beta=$ 0.196, $p=$ 0.005), as well as MM height ( $\beta=$ 0.175, $p=$ 0.019) and PF ${}_{\textit{ROM}}$ ( $\beta=$ 0.123, $p=$ 0.031) on the right side. In addition, on the left side there were strong effects for LAA ( $\beta=$ 0.732, $p<$ 0.001) and caput ossis metatarsi I ( $\beta=$ 0.101, $p=$ 0.029). The relationship between trunk hyperextension flexibility, plantar flexion ROM (right and left), and gastrocnemius flexibility measurement variables were evaluated with linear regression analysis and these parameters explained 70% of all changes. There were also strong effects on the right PF ${}_{\textit{ROM}}$ ( $\beta=-$ 0.824, $p=$ 0.000), trunk hyperextension flexibility ( $\beta=$ 0.139, $p=$ 0.008), and left PF ${}_{\textit{ROM}}$ ( $\beta=-$ 0.071, $p=$ 0.412). All parameters explain variation changes in both sides. Additionally, when we evaluated the relationship between CSAI, foot metatarsal breadth, NH, heel width, HH, and foot metatarsal circumference variables, there were strong effects from CSAI ( $p<$ 0.001), foot heel width ( $p<$ 0.001), heel height ( $p=$ 0.005), foot metatarsal width ( $p=$ 0.008), and NH ( $p=$ 0.010) on the right side. On the left side, there were strong relationships for CSAI ( $p<$ 0.001), foot heel width ( $p=$ 0.010), NH ( $p=$ 0.016), foot metatarsal width ( $p=$ 0.017), and heel height ( $p=$ 0.067) variables. All parameters explain 88.7% and 81.2% of the CSAI measurement alterations on the right and left sides, respectively.

4. Discussion

This paper is the first study that investigates the detailed relationship between HHS and the effect on the musculoskeletal system in adult females wearing HHS and NHHS. Differences in length parameters could depend on the narrow and pointed toe of the shoe. HHS distribute the pressure on the caput ossis metatarsi I (CMH ${}_{1}$ ) and compress the foot in this area. Changes in diameter and circumference measurements show females wearing HHS have more slender and aesthetic foot structure. In addition, these shoes have smaller dimensions. Moreover, HHS use has been discussed among health specialist since the 18th century. HHS lead to lower extremity problems including shortened calf muscles, foot deformity (i.e. hallux valgus, hammer toe), foot sprain, and pain [29].

Chiroma et al. reported the mean values of the foot length as 25.17 $\pm$ 1.75 cm in Nigerians [28], whereas in an Arizona population, this was established as 24.4 $\pm$ 1.2 cm [30]. Moreover, in USA, Hong Kong, and Korean females wearing HHS, the foot length was 23.4 cm, 23.8 cm, and 23.8 cm [31, 32, 33]. In a study including Slovakia females, the values were 24.22 $\pm$ 1.04 cm [34]. According to the literature, our findings [(24.26 cm (right), 24.22 cm (left)] in females wearing HHS were close to the report from Slovakia [34]. Conversely, the mean values of the Nigeria [28, 35] and Arizona [30] populations were higher than our values. The values in Korean [33] and Hong Kong populations [31] were lower than our values. Although there were no significant differences ( $p>$ 0.05), the foot lengths are greater in NHHS than in HHS wearing females. Meanwhile, Chiroma et al. reported that people living in warm climates could have longer arms and legs than people living in cold environments [28]. We think that differences in foot anthropometry may originate from adaptations to climate. These differences may result from regional, racial, gender, cultural differences in shoe heel height, shoe type (i.e. boot, sandals, sneakers, slipper etc.), shoe shape (i.e. narrow, broad etc.) or shoe habit (i.e. walking barefoot, to use or not shoe).

Few studies assess NH for the general population. In Americans, the mean value of navicular bone height was 3.46 $\pm$ 0.56 cm [36]. Moreover, this value was 3.98 $\pm$ 0.17 cm and 5.09 $\pm$ 0.40 cm in flat foot and normal foot Nigerian females, respectively [22]. According to the literature, our study values from the NHHS group were similar to a study in the USA population [36], whereas the values were higher in the HHS group than in Williams and Mc Clay’s study [36] and were close to the normal foot of Nigerian females [22]. In this investigation, NH and the distance between the Feiss line and navicular height (FLND) were 4.80 $\pm$ 0.53 cm (right), 4.77 $\pm$ 0.48 cm (left), $-$ 0.26 $\pm$ 0.36 cm (right) and $-$ 0.21 $\pm$ 0.31 cm (left) in females wearing HHS, respectively. In NHHS females, the same values were 3.57 $\pm$ 0.45 cm (right), 3.57 $\pm$ 0.40 cm (left), $-$ 1.30 $\pm$ 0.43 cm (right), and $-$ 1.37 $\pm$ 0.37 cm (left), respectively. We think these differences are caused by HHS use due to increased of foot arch structure.

In the literature, a study about truncated foot length performed with only females was not found. In the general population, Williams and Mc Clay reported the mean value of truncated foot length as 17.94 $\pm$ 1.14 cm [36], whereas in Pohl and Farr’s study this value was 18.4 $\pm$ 0.8 cm [37]. We found the mean values in the literature were higher [36, 37] than our results for females wearing HHS [(17.83 $\pm$ 0.83 cm (right), 17.72 $\pm$ 0.77 cm (left)]. Although there was no significant difference in our groups for truncated foot length ( $p>$ 0.05), these values were lower in females wearing HHS than in NHHS [(17.95 $\pm$ 0.90 cm (right), 17.91 $\pm$ 0.91 cm (left)]. This can lead to shortening of the truncated foot length because of HHS use that results in increased arch structure.

In the literature, the mean value of foot metatarsal width differs from 8.4 $\pm$ 0.6 cm to 9.90 $\pm$ 0.60 cm [19, 30, 34, 35, 38, 39, 40, 41, 42]. Our findings from females wearing HHS were similar to Indians [38, 39]. Our female population wearing HHS had loer values than the mean values of Brazilian [19], Arizona [30], Slovakian [34], Nigerian populations [35]. These differences could depend on factors including heel height, foot type and shape, and shoe habits as well as ethnic, cultural, and regional differences. In particular, the pointed toe structure of HHS may be a primary factor, because this structure triggers reduction of foot metatarsal width. Moreover, this dimension in two Turkish population studies was 9.48 $\pm$ 0.05 cm and 8.86 $\pm$ 0.52 cm [41, 42]. Our findings of females wearing HHS were lower than these studies. These differences could be a result of factors such as heel height, shoe shape, pointed-toes and HHS use for a long time.

The mean values of foot metatarsal circumference measurements were 23.8 $\pm$ 1.3 cm (right), and 23.7 $\pm$ 1.3 cm (left) in Brazilian females [19], whereas the mean values were 23.63 $\pm$ 0.17 cm [41] and 23.0 $\pm$ 1.35 cm [42] in two Turkish populations. According to the literature, our foot metatarsal circumference findings in females wearing HHS were lower than studies including Brazilian and Turkish populations [19, 41, 42]. There was a significant difference for foot metatarsal circumference value between females wearing HHS and NHHS ( $p<$ 0.05). This difference can be due to shoe shape and heel height as well as ethnic and regional factors. Moreover, malleolus medialis height (MMH) measurements were 6.46 $\pm$ 0.63 cm (right), and 6.42 $\pm$ 0.59 cm (left) in females wearing HHS. The same values were 6.20 $\pm$ 0.66 cm (right), and 6.22 $\pm$ 0.62 cm (left) in females wearing NHHS. This difference between groups may be from factors like shoe type and heel height.

Kautilya et al. reported the mean heel width value was 4.76 $\pm$ 0.49 cm (right), and 4.78 $\pm$ 0.50 cm (left) in females [39]. McPoil et al. reported 6.1 $\pm$ 0.4 cm (right), and 6.1 $\pm$ 0.4 cm (left) [30], and Yıldırım reported 6.02 $\pm$ 0.51 cm [42]. Moreover, Nadége et al. measured the same parameter in females wearing HHS as 5.33 $\pm$ 0.26 cm [43]. In our study, the mean value of the heel width was significantly lower in females wearing HHS than NHHS ( $p<$ 0.05). The mean values from Turkey and France [42, 43] were higher than our results from females wearing HHS. However, the same values were lower in Indians [39] than in our study. This may result from the HHS transmission of weight from hindfoot to forefoot. In addition, the tendo calcaneus is tightened which pulls up the heel. Therefore, there is less carrying load in the heel region. Furthermore, these differences in the literature are derived from regional, ethnic, and climatic factors, shoe type (pointed toe, narrow), shoe heel height, and less carrying load in the heel region. In our study, the mean values of the heel circumference values were lower in females wearing HHS than NHHS ( $p<$ 0.05). Additionally, in a study about the relationship between pes planus or pes cavus and foot length, foot breadth, and heel breadth, a significant positive correlation was observed between pes planus and heel breadth. Although there was no correlation between pes cavus and foot size in our study, correlation was found between heel breadth, heel circumference, foot metatarsal breadth, foot circumference, and pes cavus.

The mean values of caput ossis metatarsi I (CMH ${}_{I}$ ) were 3.1 $\pm$ 0.3 cm (right), and 3.1 $\pm$ 0.3 cm (left) in Brazilian females [19], whereas in Belgium healthy people, CM ${}_{1}$ and caput ossis metatarsi V (CMH ${}_{V}$ ) values were 2.62 $\pm$ 0.28 cm and 2.06 $\pm$ 0.27 cm, respectively [20]. In this investigation, the CMH ${}_{1}$ and CMH ${}_{5}$ values were 3.21 $\pm$ 0.28 cm (right), and 3.22 $\pm$ 0.26 cm (left), and 2.16 $\pm$ 0.23 cm (right), and 2.21 $\pm$ 0.22 cm (left) in females wearing HHS, respectively. Moreover, the same values were 2.96 $\pm$ 0.64 cm (right), 2.96 $\pm$ 0.32 cm (left) and 1.94 $\pm$ 0.35 cm (right), 1.96 $\pm$ 0.32 cm (left), in females NHHS, respectively. According to the literature, our findings were higher than both studies above. This situation may result from increased bony structure in these foot regions and carrying the crucial part of body weight on CMH ${}_{1}$ . Furthermore, the mean values of the FI were between 37.74% and 39.54% [35, 41, 42]. According to the literature, our findings were lower than both Turkish and Nigerian populations and in females wearing NHHS [35, 41, 42]. Additionally, FI is connected with both foot width and length, such that as the foot metatarsal width decreases, the FI decreases. This situation explains why the FI was lower in females wearing HHS than NHHS.

CSAI was found 0.22 in females wearing HHS, whereas it was 0.33 in females wearing NHHS [44]. Moreover, in comparing the mean value of CSAI in our study (in females wearing HHS) with that of Brazilians, our findings were higher. However, this difference may be due to heel height differences. In Pezzan et al.’ study, the heel height was 10 cm, whereas in our study it was 8.87 $\pm$ 1.82 cm. Furthermore, we think that shoe type, shoe shape, and the habit of shoe wearing at home or during leissure activities (barefoot walking, no shoe, or slippers) may effect CSAI. In our study, both CSAI and SAI values were lower in females wearing HHS than NHHS. On the other hand, foot shape is identified according to FI. In other words, Chiroma et al. evaluated foot shape in three groups [28]: slender foot, standard foot, and broad foot. In our study, there were no significantly differences in foot shapes between groups ( $p<$ 0.05).

The calf’ shape and size are determined by the calf muscles’size and bony structure, and subcutaneous tissue [45, 46]. The strength of the gastrocnemius medial and lateral heads and soleus muscles play a significant role in calf region shape and size. Much thinner or thicker calf muscles are not considered aesthetically pleasing [45]. Beauty and aesthetic appearances are increasingly more important and legs are critical for personal beauty. In our study, the lower limb circumference measurement (LCM ${}_{1}$ ) and (LCM ${}_{2}$ ) measurements were 29.62 $\pm$ 2.66 cm (right), 29.94 $\pm$ 2.83 cm (left) and 35.20 $\pm$ 2.23 cm (right), 35.33 $\pm$ 2.24 cm (left) in females wearing HHS, respectively. In females wearing NHHS, the parameters were 30.43 $\pm$ 2.44 cm (right), 30.41 $\pm$ 2.53 cm (left), and 35.16 $\pm$ 2.64 cm (right), 35.19 $\pm$ 2.59 cm (left), respectively. Moreover, for both groups, these values were ideal (33–36 cm) as specified by Szalay [45, 46]. Furthermore, the LCM ${}_{2}$ values were thickest in females wearing HHS. We think these differences arise from HHS, which lead to gastrocnemius and soleus muscles shortening and thickening.

The heel height increases ankle plantar flexion ROM. This change results in shortened plantar flexors, especially gastrocnemius muscle, and restrict ankle joint plantar flexion motion. This creates an uncomfortable situation, especially when standing to carry the body’s weight and the muscles are vulnerable to fatigue. Therefore, the knee joint is forced to bend more to release the tense muscles. The distance between the foot and pelvis is decreased which leads to a decreased range of locomotion. Finally, this condition creates a shorter stride length while walking in high heels [47]. Nwankwo et al. clarified that as heel height increases, stride length and step length decrease and whereas stride width and walking cadence increase. This may be attributed to the forward shift of the center of gravity, and altered biomechanics of the foot to prevent falls and provide postural stability [48, 49]. In our study, findings were similar to literature [47, 48, 49]. Moreover, the 6-m walking test times were shorter in females wearing HHS (5.62 $\pm$ 0.83) than NHHS (6.80 $\pm$ 1.11). This shows that the subject must step more frequently than normal to compansate the situation and provide balance.

Muscles must be long enough to provide mobility, whereas, muscles must be shorten enough to provide effective stability. A flexibility test, which measures both ROM and flexibility, may be limited by muscles, ligaments, and bony structure [13]. In addition, ankle flexibility is a crucial factor to carry out daily life activities (walking, climbing up or down stairs) confidently and maintain postural stability [50]. Oskay and Yakut reported that the sit and reach test (SRT), trunk lateral flexion (right-left) and trunk hyperextension flexibility (THF) measurements were 6.56 $\pm$ 7.05 cm, 18.08 $\pm$ 3.51 cm (right), 18.08 $\pm$ 3.86 cm (left), and 14.49 $\pm$ 4.66 cm, respectively [51]. Moreover, Katayıfçı et al. declared the same parameters were 8.0 $\pm$ 8.4 cm, 19.9 $\pm$ 3.1 cm (right), 20.1 $\pm$ 2.7 cm (left) and 24.6 $\pm$ 5.9 cm in females, respectively [52]. Furthermore, Kawano et al. found the mean value of the SRT was 30.4 $\pm$ 7.9 cm [53]. Wang et al. reported the mean values of the Hamstring ROM were 74 $\pm$ 5 ${}^{\circ}$ (dominant) and 82 $\pm$ 7 ${}^{\circ}$ (non-dominant) in long distance female runners and 86 $\pm$ 7 ${}^{\circ}$ and 86 $\pm$ 5 ${}^{\circ}$ in female non-runners [54]. Moreover, the Hamstring ROM was less on the dominant side than non-dominant side because of the inceased need of this muscle and excessive use of the muscle group on the dominant side [54]. Furthermore, the Hamstring ideal ROM of females was 80 ${}^{\circ}$ . Youdas et al. declared the same measurement as 76.3 $\pm$ 9.5 ${}^{\circ}$ in females [55]. In comparing gastrocnemius and THF, a significant difference was found between our groups. This situation may arise from excessive use of these muscles while using HHS.

In the light of this information, there are many studies about the use of HHS and the irreversible and negative effects. However, the negative effects are reduced with preventive practices such as stretching exercises or suitable shoes. If females have to wear HHS for a long time during the day, they should occasionally do specific exercises to decrease long term negative effects. Moreover, heel height should not exceed 5.08 cm and HHS should be worn for less than 4 hours and less than three times a week to ensure comfort and reduce the risk of injury [56]. Finally, foot anthropometry differs throughout society. Thus, the ideal shoe for maximum foot health would be personally customized. However, this solution is costly. So, it is unlikely to occur. Therefore, we believe that anatomists should take part in the production of suitable and orthopaedic shoes for foot health.

Footnotes

Acknowledgments

We would like to thank the Scientific Research Projects Unit of Cukurova University for financial support (grant number: TF 2014 DT-1110).

Conflict of interest

The authors declare that there is no conflict of interest.

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Wearing high-heeled shoes increases the foot arch angle inducing measurable changes in the musculoskeletal system

Abstract

BACKGROUND AND OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2. Materials and methods

Table 2 Foot anthropometric and circumference measurements in females wearing high-heeled shoes (HHS) and non-HHS (NHHS)

Footnotes

Acknowledgments

Conflict of interest

References

Table 2
Foot anthropometric and circumference measurements in females wearing high-heeled shoes (HHS) and non-HHS (NHHS)