High-Heeled Shoes and Musculoskeletal Injuries: a Narrative Systematic Review

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High-Heeled Shoes and Musculoskeletal Injuries: a Narrative Systematic Review Open Access Research BMJ Open: first published as 10.1136/bmjopen-2015-010053 on 13 January 2016. Downloaded from High-heeled shoes and musculoskeletal injuries: a narrative systematic review Maxwell S Barnish,1 Jean Barnish2 To cite: Barnish MS, ABSTRACT Strengths and limitations of this study Barnish J. High-heeled shoes Objectives: To conduct the first systematic review and musculoskeletal injuries: from an epidemiological perspective regarding the ▪ a narrative systematic review. We present the first systematic review of high- association between high-heeled shoe wear and BMJ Open 2016;6:e010053. heeled shoes and health from an epidemiological doi:10.1136/bmjopen-2015- hallux valgus, musculoskeletal pain, osteoarthritis perspective. 010053 (OA) and both first-party and second-party injury in ▪ We situate the evidence in the context of wider human participants without prior musculoskeletal public debate. conditions. ▪ ▸ Prepublication history We were able to consider evidence published in and additional material is Setting: A systematic review of international peer- seven languages. available. To view please visit reviewed scientific literature across seven major ▪ We could not include non-European languages the journal (http://dx.doi.org/ languages. and two articles were not retrievable. 10.1136/bmjopen-2015- Data sources: Searches were conducted on seven ▪ There was a lack of standardisation of heel 010053). major bibliographic databases in July 2015 to initially height cut-offs between studies. identify all scholarly articles on high-heeled shoes. Supplementary manual searches were conducted. Titles, abstracts and full-text articles were sequentially MSB is the senior author and INTRODUCTION screened to identify all articles assessing is currently at Epidemiology High-heeled shoes (high heels) are a power- Group, Institute of Applied epidemiological evidence regarding the association ful symbol of modern female sexuality1 that between high-heeled shoe wear and hallux valgus, Health Sciences, University of have been shown to increase women’s attract- Aberdeen, Aberdeen, UK. musculoskeletal pain, OA and both first-party and fl ’ second-party injury in human participants without prior iveness to men and in uence men s behav- Received 22 September 2015 musculoskeletal conditions. Standardised data iour towards women in experimental 23 Revised 10 December 2015 extraction and quality assessment (Threats to Validity studies. It has been suggested that this Accepted 14 December 2015 effect may result from an exaggeration of tool) were conducted. http://bmjopen.bmj.com/ Primary and secondary outcome measures: prototypical feminine gait.3 Compliance to Musculoskeletal pain or OA as assessed by clinical social norms45is a key driver of human diagnosis or clinical assessment tool. First-party or behaviour and fashion6 including use of high second-party injury. heels78is a clear manifestation of this. Being Results: 644 unique records were identified, 56 full- associated more with occasions than non- text articles were screened and 18 studies included occasions,78use of high heels may be seen in the review. Four studies assessed the relationship as highly desirable and even compulsory at – with hallux valgus and three found a significant certain workplaces and social events.9 12 association. Two studies assessed the association on September 30, 2021 by guest. Protected copyright. Concerns regarding the potential impact with OA and neither found a significant association. ’ Five studies assessed the association with of high heels on women s health have been musculoskeletal pain and three found a significant expressed in medical circles for over 13 association. Eight studies assessed first-party injury 50 years and in 2001 podiatrist William and seven found evidence of a significant injury toll Rossi declared footwear to be the primary associated with high-heeled shoes. One study cause of foot disorders.14 A narrative review provided data on second-party injury and the injury from an experimental biomechanical per- toll was low. spective in 201415 concluded that high heels Conclusions: High-heeled shoes were shown to be cause qualitatively consistent alterations to associated with hallux valgus, musculoskeletal pain 1Independent Scholar, the neuromechanics of walking gait and and first-party injury. No conclusive evidence Aberdeen, UK affect the kinematics and kinetics of bodily 2Retired Health Visitor, regarding OA and second-party injury was found. structures from the toes to the spine in ways Societal and clinical relevance of these findings is London, UK that may be seen as biomechanical markers discussed. Concern is expressed about the Correspondence to expectation to wear high-heeled shoes in some work of musculoskeletal conditions such as hallux Dr Maxwell S Barnish; and social situations and access by children. valgus (HV) and osteoarthritis (OA), which [email protected] are both more common in women than Barnish MS, Barnish J. BMJ Open 2016;6:e010053. doi:10.1136/bmjopen-2015-010053 1 Open Access BMJ Open: first published as 10.1136/bmjopen-2015-010053 on 13 January 2016. Downloaded from men.16 17 However, no review from an epidemiological search keywords was presented to each database. perspective could be identified and indeed a relative Supplementary searches were conducted using Google lack of epidemiological evidence was cited over 15 years Scholar, reference lists of relevant retrieved articles and ago9 as a barrier to the introduction of measures to also general internet searches using the Google search prevent women being required to wear high heels as engine to identify media coverage and/or press releases part of employer dress codes. on high heels and health in order to seek the original Moreover, the potential for high heels to inflict injury publication source. both on the wearer and on bystanders should be consid- ered. For example, Williams and Haines18 identified 240 Inclusion criteria emergency department (ED) presentations over a 5-year The following inclusion criteria were applied sequen- period in the Australian state of Victoria resulting from tially. Initially, titles and abstracts were screened and first-party injury from high heels and a further 65 result- then full-text copies of all potentially relevant articles ing from second-party injury from high heels. Since were sought. Full-text articles were retrieved in elec- pressure is inversely associated with the cross-sectional tronic form where this was available, otherwise in paper 19 area through which a force is applied, the potential copy. An array of leading research libraries were access- for high heel shoe wearing to result in injury to both the ible to the authors including the British Library. If an wearer and on bystanders should be considered. Such article could not be retrieved from any of these sources, shoes are exempt from restrictions on wear in public it was excluded. A list of excluded articles with reasons is places and age restrictions on sale that are imposed on provided in online supplementary table S1. other sharp bladed objects such as knives in countries ▸ Full-text original empirical peer-reviewed scientific 20 21 such as the UK and Australia. journal articles. The systematic review presented in this article sought ▸ Published in English, French, German, Spanish, to assess existing epidemiological evidence associating Italian, Dutch or Portuguese. exposure to high heels with at least one of the following ▸ Able to be retrieved. outcomes in human participants without clinically sig- ▸ Providing data to associate use of high heels with at nificant musculoskeletal conditions prior to measure- least one of: (1) OA, musculoskeletal pain or HV veri- ment: (1) OA, musculoskeletal pain or HV verifiable fiable either by clinical diagnosis or clinical assess- either by clinical diagnosis or clinical assessment tool or ment tool or (2) injury to first or second party. (2) injury to first or second party. ▸ Assessing human participants without prior history of clinically significant musculoskeletal conditions or other serious medical conditions likely to affect METHODS outcomes. Design http://bmjopen.bmj.com/ ▸ Using any quantitative epidemiological design includ- A systematic review design was used following the ing epidemiological elements embedded into bio- PRISMA statement22 adapting the approach to the epi- mechanical studies. demiological rather than interventional nature of this review. MSB was the lead reviewer and JB performed Data extraction and quality assessment independent quality assurance on a 20% sample of title screening, abstract screening, full-text screening, data Data were extracted onto a standardised data extraction extraction and quality assessment. Any discrepancies form. The following data were collected: bibliographic details, language of publication, country of study, study were resolved by discussion between the reviewers. on September 30, 2021 by guest. Protected copyright. Searches were designed and conducted by MSB. design, participants, measures of exposure, measures of outcome and principal findings. MSB contacted corre- sponding authors where appropriate to seek required Data sources clarifications. Measures of heel height that had been The bibliographical databases MEDLINE (Ovid), expressed in inches were converted to cm at 1 EMBASE (Ovid), AMED (Ovid), PsycINFO (Ovid), inch=2.54 cm.23 Only aspects of studies that meet inclu- Cochrane Central Register of Controlled Trials sion criteria for this review
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