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The New York Times: In the Relentless Pursuit of Fashion, the Feet Pay the Price

Americans seem to suffer a disconnect between what logic dictates is good for their health and what they do. They exercise, but they also sunbathe. They eat large salads instead of dinner, but snack on high-calorie, high-cholesterol junk foods.

This habit extends down to the toes, or at least the toes of many women. Just ask the podiatrists and foot and ankle surgeons who do a brisk business in repairing feet wounded by the fashion industry’s love affair with high-heeled shoes.

”The current trend in fashion is very bad for women’s feet,” said Dr. Lloyd Smith, president of the American Podiatric Medical Association, who practices in Newton, Mass. ”Superhigh heels with very narrow toes create problems and exacerbate existing conditions.”

Round-toed shoes with five- or even six-inch heels, fashionable this season, are hardly better; likewise the popular thong sandals, which completely expose the feet.

”Flip-flops are close to horrible for the feet,” Dr. Smith said. ”They are totally flat, soft and squishy, and offer no support and no protection,” not to mention their penchant for causing accidents by catching on things or inviting being stepped on.

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Even athletic shoes, experts say, occasionally lead to problems that require medical intervention.

Medical experts agree that the best shoes for healthy feet mimic the foot’s natural shape, while offering support in the arch and a flexible sole underneath the toes, the way most athletic shoes do.

”A good shoe has a relatively flat sole and something that fits the heel snugly,” Dr. Smith said. ”There is lots of room in the toe box for the toes, and the uppers are of soft materials. Ideally laces make the shoe adjustable.”

So-called healthy shoes manufactured by the athletic industry bring in $11 billion annually, nearly one-third of the $35 billion Americans spend on shoes each year, said Marshal Cohen, chief industry analyst for the NPD Group, a fashion market research organization.

But Mr. Cohen said sales data indicated double-digit growth for women’s dress shoes in the last four months.

High heels can be bad for wearers for several reasons, said Dr. Tzvi Bar-David, a doctor of podiatric medicine at Columbia Presbyterian Medical Center in New York.

An elevated heel lifts the foot out of its natural position and shortens the Achilles’ tendon. Such shoes also pitch the weight of the body forward disproportionately onto the ball of the foot, which in turn upsets the stabilizing mechanics of the foot.

”High heels have a narrow area of contact and they point the toes downward, which puts the foot in an internally rotated position and makes their wearer more prone to spraining an ankle,” Dr. Bar-David said.

The padded human heel is there to absorb the shock, he said. When the heel hits the ground, the pressure is that of two and a half times one’s body weight.

”When you walk on your heel, you need to be able to absorb the impact of the heel strike,” Dr. Bar-David said. ”Your foot then becomes a rigid stabilizer, so you can push off in the toes in a balanced way. You don’t want that rigidity to travel up through your bones.”

Pain in the back, neck and knees can be the result of shock that travels up the skeleton from a nonresilient heel.

”When you start playing around with shoes that take away from the natural functions of your feet, you start to have problems,” Dr. Bar-David said.

In addition, fashionable shoes that try to convert the foot into an ideal form, with the toes narrowed or tapered to a point, often require cramming the foot into less space than it would normally occupy.

Regular tight shoes put pressure on nerves and even damage them, and also contribute in the long run to arthritis, doctors say. Shoes with pointed toes or stiff soles, like the leather versions common in many high-quality shoes, can impede the foot’s mechanical function by limiting toe and ankle flexibility, said Dr. Thomas Novella, who practices podiatric medicine in Manhattan and counts many professional dancers and athletes as well as leisure-time runners among his patients.

”Metatarsal pads or stiff shoes inhibit the toes’ range of motion and can make you lose toe strength,” Dr. Novella said. ”You are cheated of the power of your toes, those little muscular soldiers lined up in your feet that are there to help carry you forward.”

Dr. Novella said inflexible toe beds were one of the most common causes of shin splints. ”If you can’t push off with your toes, you begin to pull up or grip with them,” he said. Because tendons in the toes attach to the tibia, when the toes tug, it can register in the shins.

Tight shoes also can produce foot deformities in the toes, and can lead to symptoms from deformities that might otherwise go unnoticed, said Dr. Gary Jolly, president of the American College of Foot and Ankle Surgeons, who practices in Hartford. People have a genetic predisposition toward bunions and hammer toe deformities, he said, but shoes are often the factor that turn conditions into problems.

”Almost all bunion surgeries are done on women,” he said, adding that because men’s shoes normally fit the natural contours of the foot and have plenty of space inside, men may have bunions but no pain.

”I don’t remember the last time I did a bunion surgery on a man,” Dr. Jolly said.

He also advised against a practice that is becoming more common: surgery for exclusively cosmetic reasons, like having toes shortened, straightened or even removed so the foot will fit into fashionable shoes.

”The foot is a highly unique weight-bearing mechanism with a rich network of nerve endings, and a complex system of muscles and ligaments that stabilize it,” Dr. Jolly said. ”Foot surgery carries risks that can be greater than the more common forms of cosmetic surgery.”

He added that the college of surgeons did not support this surgery when there was no medical gain.

Bunion surgery is sometimes deemed elective by insurance companies. Dr. Smith, who said bunion surgeries in his practice had doubled last year, also said recuperation time had recently been cut in half, to an average of six weeks from three months.

Increasingly, bunions and other foot ailments are being treated in earlier stages with orthotics. The American Podiatric Medical Association reports that about 13.7 million Americans over 18 have used prescription orthotics at some time, and 23.5 million more have bought orthotics over the counter, though few of the devices will fit into a high-fashion dress shoe.

Orthotics are used to do more than fix foot pain, said Dr. Lori Weisenfeld, a podiatrist who began practicing 15 years ago with her father, the late Dr. Murray Weisenfeld, who wrote ”The Runners’ Repair Manual.” Dr. Weisenfeld said imbalances that begin in the feet can create groin pulls, knee pain, and back and neck pain.

”When the alignment is off or the range of motion is limited in the foot, other joints compensate for it, and this is what often causes pain,” Dr. Weisenfeld said. ”An orthotic can correct faulty biomechanics, including how the foot is tilted. It can disperse pain away from painful areas by taking the pressure away.”

Foot specialists agreed that the wide variety of athletic shoes make it almost worth seeking the advice of a medical professional before selecting a pair.

”People need to choose the right shoe for their foot type and their activity,” Dr. Weisenfeld said. For example, she said, people with high arches may need more cushioning, and people with relatively flat feet may need more arch support.

Dr. Novella said he had seen innovations in athletic shoes that caused problems, including plantar fascial tears from overly flexible arches. He has also seen bruised heels and sprained ankles from shoes with heels that were soft on the outside and hard inside, he said.

His advice to his patients is that if the shoe fits, keep on wearing it, and if pain coincides with a new pair of shoes it is probably the fault of the shoes.

”I tell my patients, ‘Don’t throw your old running shoes away until you are comfortable in your new ones,”’ Dr. Novella said. ”You may save yourself a trip to the doctor, simply by comparing the old with the new and finding what is different.”

With all this use and abuse of feet and fashionable foot flesh on display, it is no surprise that the pampering and repairing of feet has become a booming industry.

Day spas have evolved new therapies for comforting tired, well-used, expensively shod feet. There are hot-towel foot ”facials”; grainy rubs to remove the outer layers of dry skin; soaks of rosewater and milk or almond oil; and lengthy massages, which often use applications of stimulating menthol, which gives the skin a rosy glow.

Regina Viotto, director of the Paul Labrecque Salon on the East Side of Manhattan, said the recent expansion of the foot-care department had helped accommodate the growing numbers of male customers, but catered particularly to women who were committed to their high-fashion high heels.

”We are aware of women’s obsession with their Jimmy Choos and their Manolos,” she said, mentioning two high-end shoe designers. ”We know these shoes are hard on the back and the body, so we have focused on creating relaxing treatments that alleviate the stress that women are putting on their feet.”

Dr. Novella held out hope for at least some women and their favorite shoes. He said that his goal was always to keep patients in ”asymptomatic equilibrium,” and that the formula was highly individual.

”There are certain ways to test a person’s calf tightness, as well as using other parameters which help you determine the degree of heel height the person should wear,” he said. ”The fact is some women are more comfortable in high heels.”

He added that jumping suddenly from stilettos to flats — or from daily flip-flops to high heels — was not a good idea.

”Human tissues can adapt, and the best way to allow your tissues to adapt is to make no rapid changes,” he said. ”I tell my patients that changes in footwear and training should always be gradual — evolutionary, not revolutionary.”

Simon Doonan, the creative director of Barneys New York, had a simpler explanation for women’s ability to wear the shoes they love.

”Women have a higher pain threshold,” he said. ”Men would not do this.”


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