High-Heel Wearing Does Not Change The Forefoot Alignment In Non-Frequent Users Without Hallux Valgus: 3D Weight-Bearing Scan Study
Authors: Mann Tania Szejnfeld , Fayed Aly M. , Mansur Nacime Salomao Barbachan , Carvalho Kepler A.M. , Talaski Grayson M. , Kim Ki Chun , Nunes Gustavo Araujo , Nery Caio , Nishikawa Danilo Cândido , de Cesar Netto Cesar 
Published: December 2023

Category: Lesser Toes; Midfoot/Forefoot Introduction/Purpose: Women wearing high heels for 20 years without Hallux valgus angle alterations make it debatable that causes Hallux valgus deformation. A recent systematic review determined that 4.13 ± 0.34 cm of heel height would improve foot weight-bearing . Wearing high heels would realign the foot, causing an inversion of the foot, which locked the navicular-cuneiform and cuneo-metatarsal joints rather than primarily rotate the metatarsophalangeal joint. Nowadays, weight-bearing scans could favor understanding the alignment mechanism involved in the foot and ankle with different shoe heights. Therefore, we aimed to determine the acute foot alignment in non-frequent HH users without Hallux valgus during stand posture. Here, we hypothesize that high heels studied by weight-bearing scans shows radiology changes linked to hindfoot alignment rather than primary forefoot rotation. Methods: This comparative cross-sectional study, participants were randomly submitted to a tridimensional weight-bearing CT. Foot alignment for barefoot and wearing custom high heels of 3, 6, and 9 cm. Forty-one feet from twenty-one participants (11 males and 10 females, aged 30.8 ± 8.9 years, and Body Mass Index 25.5 ± 2.0 m kg-2) were submitted to a tridimensional weight- bearing scan in barefoot and wearing high heels of 3, 6, and 9 cm. The inclusion criteria were: Aged between 20 and 50 years, and no regular wearing of heels.Participants were instructed to bear weight in their regular standing upright posture, dispensing the body weight uniformly between the lower limbs with the feet set at shoulder width. Declination talar, forefoot arch, foot ankle offset, 1st, 2nd, and 3rd metatarsophalangeal dorsiflexion, and metatarsal rotation and sesamoid rotation angles were compared with repeated measurement analysis and multiple comparisons as well as the raters intraclass coefficient. Results: When height increases, the declination talar angle decrease (p < 0.001), the foot ankle offset decreases (p < 0.001), the 1st, 2nd, and 3rd dorsiflexion angle increases (p < 0.001), and metatarsal rotation angle (p=0.696) and sesamoid rotation angles (p=0.649) did not change. The forefoot arch for 6 cm was higher than 3 cm (p < 0.001) and then 9 cm (p=0.001), and the forefoot arch for 9 cm was higher than 3 cm (p=0.049). Conclusion: The main finding was that increased forefoot arch, lower ankle offset, no metatarsal rotation angle, and no sesamoid rotation angle strongly suggest an acute primary hindfoot alignment adaptation mechanism rather than forefoot rotation with increase of heel heigth. The most critical mechanism combines the activation of the windlass mechanism together with a stiffer alignment of Hindfoot. Our interpretation here is supported by the lower FAO, and increased forefoot arch and metatarsophalangeal joints, giving insight into pathology foot deformation like Hallux valgus. Thus, our findings suggest that it is debatable that wearing high heels can trigger forefoot deformity,