John K. Hyland, DC, MPH, DACBR, DABCO, CSCS
Women differ from men in structure and biomechanics, and their feet are among the most different of the structures. In spite of this, we often tend to treat female patients who have foot imbalance and lower extremity dysfunction in the same way that we treat our male patients. It is vitally important to remember and review the several important areas of difference, so that we can provide specific and effective care.
Women’s feet are different in shape and size, their knee alignments and gait styles are very dissimilar, and they are encouraged to wear very different shoes. Joint problems and symptom patterns differ, so orthotic solutions need to be specific. As women age, their foot problems tend to become more severe, often resulting in significant disability and problems with walking.1 Appropriate lower extremity treatment and spinal support depend on differentiating each woman’s needs.
Foot Shape. The shape of a woman’s foot varies in several ways from a man’s. The female foot tends to have a narrower heel (in relation to the forefoot), and is narrower overall than a man’s foot relative to its length.2 The Achilles tendon is smaller in circumference and strength, but it is also shorter. Because of the narrow heel and foot, the forefoot is relatively quite wide. This causes the biomechanical forces on the foot to be distributed in a different manner.
Foot Problems. Women tend to develop biomechanical problems and symptomatic conditions in the forefoot more frequently than men. Bunions (hallux valgus), hammer toes, callus formation, interdigital neuromas and metatarsalgia are all more common in women.3 Many of these conditions have been linked to abnormal biomechanical forces in the feet.
Using weightbearing radiographs, researchers demonstrated the correlation of hallux valgus and medial arch collapse. They found “the single most dominant variable affecting metatarsal pronation (and hallux valgus) was the height of the medial longitudinal arch.”4 Using a different approach, other investigators compared weightbearing X-rays of the hindfeet in normal female subjects to those with hallux valgus. They found that the calcaneus and talus in the feet with hallux valgus had excessive pronation.5 Another recent study has confirmed that callus formation is closely associated with several specific “abnormal foot weightbearing patterns.” These are: a lower medial arch with greater pronation, reduced dorsiflexion of the first metatarsal joint and limited ankle dorsiflexion (due to calf muscle tightness).6
Solution. Every woman needs to wear shoes that have been designed for the gender-specific needs of the female foot. This means a shoe that is narrow at the heel and widens substantially at the forefoot. It should have a short, but wide toebox, and some mechanism (such as laces or straps) to keep the narrow heel in place during gait. Unfortunately, this describes very few of the shoes currently bought and worn by women in our society. Certainly, traditional high heels and pumps do not fall into the healthy shoe category.
Orthotics for women should be designed to support the longitudinal and anterior transverse arches,7 to provide metatarsal padding, and to limit excessive heel motion. Researchers have found that small, dense metatarsal arch pads positioned more distally are most effective in reducing the pressures on the metatarsal heads.8 One study of patients with metatarsalgia found that custom-made orthotics with a “metatarsal dome” decreased the plantar pressures by an average of 17% and reduced the reported pain 71%.9
Patellar Tracking. The Q-angle measures the alignment of the quadriceps muscle’s pull from the pelvis to the patella, and the patellar tendon’s pull from the tibia. Since large forces are transmitted through the patella during knee movement, any increase in the angle will result in tracking problems and, eventually, symptoms. We know that women tend to have higher Q-angles than men (Fig. 1). The normal range ends at 15 in males and 20 in females.10 Whenever a patient has excessive pronation of the foot, Q-angle stresses are magnified. Prolonged time in pronation causes excessive internal rotation of the tibia, impeding its normal external rotation during gait progression in the stance phase.11 This excessive internal tibial rotation transmits abnormal forces upward in the kinetic chain and produces medial knee stresses, force vector changes of the quadriceps mechanism, and lateral tracking of the patella.12 The combination of a higher Q-angle with excessive pronation causes many women to progress from knee dysfunction to patellofemoral arthralgia to degenerative joint disease in the knee.
Anterior Cruciate Ligaments. Female athletes appear to sustain knee injuries more frequently than their male counterparts in similar sports.13 Many of these are non-contact ruptures of an anterior cruciate ligament (ACL).14 Many theories have been proposed to explain the greater susceptibility of women to ACL tears. Some of these include a smaller intercondylar notch, hormonally-mediated ligament laxity, and gender-related differences in muscle strength and balance. One of the most promising concepts considers the alignment of the foot and knee during strenuous sports activities. Researchers have found that whenever the leg is internally rotated, the ACL is much more susceptible to injury. One study by Arnold et al. found that 81% of athletes with injury to the ACL recalled the moment of injury as having their tibia in internal rotation combined with a sudden change of direction at foot strike.15 Other researchers have found excessive pronation of the foot and collapse of the arch during weightbearing to be more common in ACL-injured subjects, and proposed that the subsequent excessive tibial rotation was the mechanism of their injury.16 Another study found that ruptures of the ACL in female athletes were directly correlated with the amount of arch collapse and hyperpronation.17
Solution. The most effective way to decrease a high Q-angle and to lower the rotational stress on the knee joint is to prevent excessive pronation with custom-fitted foot orthotics.18 The orthotics should support the foot’s arches (but especially the medial longitudinal arch) and may need to include a pronation wedge under the calcaneus. One study found that using soft corrective orthotics was more effective in reducing patellofemoral pain in women than a physical therapy exercise program.19
Fashion Victims. The fashion industry perpetuates the image of the “sexy” woman in high-heeled shoes. Many women wear heels that plantarflex the ankle and place increased pressures on the forefoot and metatarsal heads. Even a heel as low as ¾ inch has been found to increase the pressure on the forefoot by as much as 22%.20
Sizes and Fit. Constrictive shoes accentuate the problems of high heels, and they create problems of their own. A study of 356 healthy women found that 88% were wearing shoes that were significantly smaller than their feet.21 The average difference measured between the shoe and the foot was 1.2 cm (Fig. 2)! Eighty percent of the women in the study stated that they had some foot pain (almost all in the forefoot). Interestingly, in those women who reported no foot pain, the average foot-shoe discrepancy was only 0.56 cm. The researchers recommended that women should always buy their shoes by fit, and not by size, and that shoes should always be tried on at the end of the day and be fitted to the weightbearing foot.
Solution. All female patients should have their footwear checked for fit, since many are wearing shoes that don’t fit their feet, with heel heights that increase the pressures on the fronts of their feet. One easy method to check shoe fit is to trace each foot during standing, and then trace the shoe (as was done in the shoe survey described above). Any significant discrepancy means that the foot is cramped when standing and restricted during gait. When a higher heel is worn, more pressure is exerted on the forefoot, making proper fit more critical.
A properly designed orthotic support should maintain all three of the foot’s arches, and support for the anterior transverse (metatarsal) arch is especially important for women. However, no orthotic can support the foot correctly if it is placed in an improperly fitted shoe. Shoe size, both length and width, must allow for correct biomechanics during gait.
Most women need to have their feet rechecked for correct size, and many will need to purchase new shoes. Foot Levelers’ custom-made functional orthotics are available to fit in many different styles of shoes, so proper selection is important. Virtually all women will need more than one pair of orthotics—and the Sassy™ custom orthotic was designed to meet women’s special needs (Fig. 3).
All patients should have their footwear checked for fit, but this is especially important for women, who often wear mal-fitting shoes, and whose higher heels can significantly increase forefoot pressures. Research has shown that many lower extremity conditions in women are associated with or directly caused by abnormal biomechanics of their feet. Properly designed orthotic support for women—such as Sassy custom orthotics—should maintain all of the arches and reduce impact loading. However, support for the anterior transverse (metatarsal) arch, and control of overpronation at the heel appear to be particularly important.
Remember that no orthotic can support the foot correctly if it is placed in an improperly fitted shoe. Shoe size, both length and width, must allow for correct biomechanics during gait. For many women, education regarding shoe fit and addressing lower extremity biomechanics will help prevent some of the disability commonly associated with aging.
- Comparison of the responsiveness of the foot health status questionnaire and the Manchester footpain and disability index in older people. Menz HB, Auhl M, Ristevski S, Frescos N, Munteanu SE. Health Qual Life Outcomes. 2014 Oct 25;12:158. doi: 10.1186/s12955-014-0158-4.
- Cross-sectional analysis of foot function, functional ability, and health-related quality of life in older people with disabling foot pain. Mickle KJ, Munro BJ, Lord SR, Menz HB, Steele JR. Arthritis Care Res (Hoboken). 2011 Nov;63(11):1592-8. doi: 10.1002/acr.20578.
- Foot pain, plantar pressures, and falls in older people: a prospective study. Mickle KJ, Munro BJ, Lord SR, Menz HB, Steele JR. J Am Geriatr Soc. 2010 Oct;58(10):1936-40. doi: 10.1111/j.1532-5415.2010.03061.x. Epub 2010 Sep 9.
- Gait instability in older people with hallux valgus. Menz HB, Lord SR. Foot Ankle Int. 2005 Jun;26(6):483-9.
- Foot pain: is current or past shoewear a factor? Dufour AB, Broe KE, Nguyen US, Gagnon DR, Hillstrom HJ, Walker AH, Kivell E, Hannan MT. Arthritis Rheum. 2009 Oct 15;61(10):1352-8. doi: 10.1002/art.24733.
- Foot health and shoewear for women. Frey C. Clin Orthop Relat Res. 2000 Mar;(372):32-44.
- The effect of subtalar joint posting on patellar glide position in subjects with excessive rearfootpronation. Klingman RE, Liaos SM, Hardin KM. J Orthop Sports Phys Ther. 1997 Mar;25(3):185-91.
- Effects of a Multimodal Exercise Program on Physical Function, Falls, and Injuries in Older Women: A 2-Year Community-Based, Randomized Controlled Trial. Patil R, Uusi-Rasi K, Tokola K, Karinkanta S, Kannus P, Sievänen H. J Am Geriatr Soc. 2015 Jul;63(7):1306-13. doi: 10.1111/jgs.13489. Epub 2015 Jun 26.
- Evaluation of Men’s and Women’s Gymnastics Injuries: A 10-Year Observational Study. Westermann RW, Giblin M, Vaske A, Grosso K, Wolf BR. Sports Health. 2015 Mar;7(2):161-5. doi: 10.1177/1941738114559705.
- Risk factors for anterior cruciate ligament injury in high school and college athletes. Woodford-Rogers B, Cyphert L, Denegar CR. J Athl Train. 1994 Dec;29(4):343-6.
- Systematic review of the quality of randomized controlled trials for patellofemoral pain syndrome. Bizzini M, Childs JD, Piva SR, Delitto A. J Orthop Sports Phys Ther. 2003 Jan;33(1):4-20. Review.
- The influence of revised high-heeled shoes on foot pressure and center of pressure during standing in young women. Bae YH, Ko M, Lee SM. J Phys Ther Sci. 2015 Dec;27(12):3745-7. doi: 10.1589/jpts.27.3745. Epub 2015 Dec 28.
- Effect of revised high-heeled shoes on foot pressure and static balance during standing. Bae YH, Ko M, Park YS, Lee SM. J Phys Ther Sci. 2015 Apr;27(4):1129-31. doi: 10.1589/jpts.27.1129. Epub 2015 Apr 30.
- Biomechanical simulation of high-heeled shoe donning and walking. Yu J, Cheung JT, Wong DW, Cong Y, Zhang M. J Biomech. 2013 Aug 9;46(12):2067-74. doi: 10.1016/j.jbiomech.2013.05.009. Epub 2013 Jul 12.
- Influence of high-heeled shoes on venous function in young women. Tedeschi Filho W, Dezzotti NR, Joviliano EE, Moriya T, Piccinato CE. J Vasc Surg. 2012 Oct;56(4):1039-44. doi: 10.1016/j.jvs.2012.01.039. Epub 2012 Apr 5.
- What are causes and treatment strategies for patellar-tendinopathy in female runners? Grau S, Maiwald C, Krauss I, Axmann D, Janssen P, Horstmann T. J Biomech. 2008;41(9):2042-6. doi: 10.1016/j.jbiomech.2008.03.005.
- Effect of a metatarsal pad on the forefoot during gait. Koenraadt KL, Stolwijk NM, van den Wildenberg D, Duysens J, Keijsers NL. J Am Podiatr Med Assoc. 2012 Jan-Feb;102(1):18-24.
- The effect of 3 foot pads on plantar pressure of pes planus foot type. Nordsiden L, Van Lunen BL, Walker ML, Cortes N, Pasquale M, Onate JA. J Sport Rehabil. 2010 Feb;19(1):71-85.
- Foot posture, leg length discrepancy and low back pain–their relationship and clinical management using foot orthoses–an overview. Kendall JC, Bird AR, Azari MF. Foot (Edinb). 2014 Jun;24(2):75-80. doi: 10.1016/j.foot.2014.03.004. Epub 2014 Mar 19. Review
- Dose-response effects of customised foot orthoses on lower limb kinematics and kinetics in pronated foot type. Telfer S, Abbott M, Steultjens MP, Woodburn J. J Biomech. 2013 May 31;46(9):1489-95. doi: 10.1016/j.jbiomech.2013.03.036. Epub 2013 Apr 28.
- Association between foot type and lower extremity injuries: systematic literature review with meta-analysis. Tong JW, Kong PW. J Orthop Sports Phys Ther. 2013 Oct;43(10):700-14. doi: 10.2519/jospt.2013.4225. Epub 2013 Aug 30. Review.
- The effect of Q-angle on ankle sprain occurrence. Pefanis N, Papaharalampous X, Tsiganos G, Papadakou E, Baltopoulos P. Foot Ankle Spec. 2009 Feb;2(1):22-6. doi: 10.1177/1938640008330769. Epub 2009 Jan 8.
- The relationship between the height of the medial longitudinal arch (MLA) and the ankle and knee injuries in professional runners. Nakhaee Z, Rahimi A, Abaee M, Rezasoltani A, Kalantari KK. Foot (Edinb). 2008 Jun;18(2):84-90. doi: 10.1016/j.foot.2008.01.004. Epub 2008 Mar 18.