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Possible Litigation re negative heeled shoes

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Envo2010, Jan 8, 2009.

  1. Envo2010

    Envo2010 Member

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    I had a case a few weeks ago with a patient who has ruptured her Achilles tendon shortly after using a negative heeled shoe. The patient is a little overweight, generally uses footwear over 1.5 inches heel height, with ankle ROM on other side suggestive of some mild pre-existing ankle limitation probably from general accomodation. She has used running shoes to walk in for several years with no adverse effects.

    She has raised the possibility of suing the shoe company and I took the liberty of writing to them just to get their comments regarding the shoes. They have responded saying that it is their contention that negative heels offer many health benefits - promote more upright posture and distribute weight through the feet in a more natural way. Also that this altered posture helps improve venous return. Regarding tendons it is suggested that the shoes offer major benefits to tendons and can prevent problems, not cause them.

    My feelings are that any negative heel scenario will force an anatomical compemnsation based on available sagittal plane motion but there is a risk to people with pre-existing ankle limitation and physiological reduced tissue resistance. I have not seen any evidence as to proven venous return - perhaps they are suggesting it is general increased muscle activity effect. Definitive studies seem few and far between. There is also the suggestion that they are useful in pregnancy but the hormonal changes with increased laxity might make injury even more likely depending on the mechanical function.

    I'd appreciate comments, the shoes did not have any disclaimer re possible complications and the patient claimed she broke them in gradually.

    This injury is clearly going to cause considerable disruption to the patient and she suggests that she never had any problems prior to using the shoes and would not have used them if she thought there would be a risk of such an injury.

    I'd be interested in comments from the group


    Bob Fleck
    Department of Trauma and Orthopaedics
    Newcastle upon Tyne
  2. Cameron

    Cameron Well-Known Member


    I have no legal background so am unable to give an informed opinion on that aspect other than to say it would be very difficult to prove liability based on cause an effect in this case. There are too many variables I fear. I would agree when professionally dealing with people used to wearing a heel it would be prudent to advise them not to change their style of footwear for risk of aggravating injury.

    The number of people who do genuinely suffer an injury from wearing heeless shoes may be statistically insignificant and the probability of injury so low as to be considered negligible. In which case suppliers may be under no obliation to fore warn consumers and to do otherwise may appear unecessarily alarmist. If on the other hand a series of individual cases were collected that showed cause and effect then the evidence may confirm a pattern.

  3. Bob,
    Welcome! Firstly, you'd need to demonstrate an increase in achilles loading in association with wearing these shoes. Nice little project for you ;)
  4. Bob:

    Welcome to Podiatry Arena.

    I think that instead of suing the manufacturer of the low-heeled shoes, that the patient should sue all the manufacturers of the high-heeled shoes she has worn over the past few decades that have caused an accommodative shortening of the gastrocnemius-soleus complex that then prevented her from walking in a slightly negatively heeled shoe without injuring herself. In addition, she should probably sue the fast-foot restaurants and candy bar manufacturers that have led to her increased body mass (or as we say here in the US, her being "under-tall").

    Attorneys got to eat too!:rolleyes:
  5. David Smith

    David Smith Well-Known Member


    I have to agree with you Bob the general population should be cautious about using negative heels. Many of these 'revolutionary new shoes' companies have given funding to universities to use in research using their shoes. Then they say in advertising as tested by XYZ university as if testing = approval or endorsement.

    The marketing of most of these shoes appeals the the female proclivity of wanting it all for no effort, all the gain for no pain. These shoes work the buttocks and thighs an give you a complete leg work out while you walk round the shops. And here's the picture of the 22yr old model with perfect legs wearing the 'revolutionary new shoes' to prove it. Most importantly they come in many cool colours and Jennifer Aniston wears them. Basically the science is boll*cks and the marketing is top notch.

    If increased muscle action = better walking, then strap a couple of house bricks to your feet (with a negative heel) and chuck a hundredweight of spuds over your shoulder and take a leisurely stroll up a long hill. Amazingly you'll feel like you've just done a leg blasting workout while just having a stroll.

    Surely walking is about getting from A -> B in the most efficient manner and with as little effort as possible. In this way I can walk 25miles without pain (well not me but some people could). According to these 'revolutionary new shoe' adverts a walk to work makes your legs and buttocks feel the burn. Drag a truck tyre to work everyday that'll do it too! is it the optimal walking technique that is easy and will prevent injury and trauma? Probably not.

    The makers and advertisers of these shoes and us (podiatrists) have two different objectives in terms of shoe performance and effect. We want to promote footwear that optimises gait in terms of reduced pathology they want to promote footwear that appears to give something for nothing, is this possible? do you think Deena Kastor or Paula Radcliffe would like running shoes that increased buttock and thigh muscle activity so that they got a burn after 15 minutes? Have they got great legs? sure.

    If you need to recruit more muscles and make them work harder to achieve the same walking velocity then surely there must be something forcing the increased effort to be necessary - Newtons 3rd law every action has an equal and opposite reaction. If the opposing forces are increased then internal forces must be increased, which by my reasoning must result in increased tissue stress and joint forces. Now this may not necessarily be pathological until we think about how those forces opposing forward motion are created. It's not a heavy sack of spuds or a truck tyre, its the forced kinematic function (you may say dysfunction) of the joints causing an increase in muscle kinetics and ground reaction forces. This surely must increase the potential for trauma to occur because of the natural tendency for compensatory actions to facilitate forward motion and increase walking efficiency.

    This might depend on whether you believe that compensations occur to resolve problems of motion in this case saggital plane motion. I think they do and so a person with a negative heel shoe for instance may choose to walk on their toes or toe out or pronate more or bend their knees or early heel lift (or stretch / tear the Achilles tendon) etc, etc or some combination of these.

    The claim is often made that these 'Revolutionary new shoes' are like walking naturally in bare feet on natural ground. This is not so, if they start with the premise that man made ground is hard and flat and natural ground is soft and lumpy, and we go along with that, then the problem here is that the shoe ground interface is still hard and flat. Therefore the foot still has the same repetitive reaction with each footstep. If we walk on really rough grassland then sometimes we walk on our heel sometimes on our forefoot sometimes on our midfoot. Sometimes we really strain our Achilles tendon and other times we really strain our medial ankle tissues and sometimes we stress the tissues hardly at all etc, etc. When we walk on flat hard ground with our negative heel we always strain our Achilles tendon, unless we make some compensation to avoid this, Therefore there are always increased ankle dorsiflexion moments by GRF, which impede forward progression (Newtons 3rd).

    Therefore I would say that the very argument that the shoe manufacturers use to support the 'beneficial' actions (as they see it) of their shoes, does in fact support the contrary view that they also potentially increase the possibility of pathology.

    So in conclusion these shoes can be both beneficial and pathological depending on which action you choose to focus on i.e. they will work your muscles harder but also tire you out quicker and possibly cause injury.

    That's how I see it

    cheers Dave
  6. David Smith

    David Smith Well-Known Member



  7. efuller

    efuller MVP

    A little more history would be helpful. Did she gradually get increasing pain in the Achilles over the month(?) that she wore them? Did she rupture when she was running to catch a bus? If you were going to blame the shoes, it would have to be a repetative trauma injury and there should be some indication prior to the traumatic injury. If there were absolutely no symptoms prior to the rupture then I don't see any way you could blame the shoes. Has anyone heard of a rupture occuring when walking at normal speeds?

    Marketing crap that they would not, and probably should not change (because of their liability), when you mention possible lawsuit. If make it difficult to get weight on the heel, there will be a shift in center of pressure forward that will cause a dorsiflexion moment. That dorsiflexion moment has to be resisted with something and one of those things is the Achilles tendon. Long term use of shoes with negative soles will tend to increase Achilles tendon usage.

    Shoes are kind of like orthotics. If a patient tries to sue you for pain caused by them, part of the defense will be "Why didn't you stop wearing them if they hurt?".


  8. Dananberg

    Dananberg Active Member

    From the earliest days of Earth Shoes and the Kelso idea of the negative heel, I have often thought of these shoes as being designed to make people "walk up-hill". Hardly a revolution!

  9. Peter

    Peter Well-Known Member

    Hi Bob,

    I don't think the case will get far. 4" heeled stilletos don't come with a disclaimer, and we have all seen lasses falling off them and injuring their ankle joint ligaments, without the risk to the shoe manufacturer of lawsuits.

    Interesting test case though.
  10. David Smith

    David Smith Well-Known Member


    This has been said before but its not really like walking up hill more like walking in pot holes.With your heel always in the bottom of the hole. This is because when walking up hill the leading foot placement is higher than the back foot but in this case the leading foot heel strike is below (or potentially below ) the level of the back foot's toes. This increases the achilles tension and therefore forefoot GRF and does not have the benefit that the flexed knee of the leading leg can raise the CoM as it extends and reduce GRF on the back foot. Therefore saggital plane progression is severely blocked.

    As a point of interest my clinic used to be near an army camp used by the Gurka Regiment (Nepalese soldiers serving in the British Army). When they came to me I would notice that they always had extreme ankle dorsiflexion RoM 30 or 40dgs+.
    Was this a genetic or physiological change due to adaption to the mountainous terrain of Nepal? I don't know but I suspect they would be fine in negative heel shoes as implied by Kevin earlier.

    Cheers Dave
  11. Cameron

    Cameron Well-Known Member


    According to the web it was Yoga student, Anne Kalso who noticed stretching her heel below the ball of her foot she felt the same as when she was sitting in the Buddha position (lotus) of meditation. She and a shoe maker experimented with shoe design until they developed and refined the negative heel shoe. Earth shoes had a thicker sole under the ball of the foot with no heel and stretched the tendo Achilles with each step. Despite a flurry of fashion interest and cult following by the few, the negative heel shoe had a mixed reception due mainly to discomfort reported when breaking them in. Flat Exercise sandals had similar problems and although loyally worn by those who overcame initial teething troubles they were abandoned in their millions, by others.

    Professor Vladimir Janda trained as a neurologist before specialising in manual medicine and rehabilitation. His special interest was in the complex nature of chronic pain syndromes and how manual techniques integrated neurologically and he became known worldwide for his research linking muscle dysfunction and chronic pain syndromes. Clinically he was a proponent of manipulation, myofascial procedures and exercise, but found each approach alone was insufficient for the chronic syndrome. Janda’s research established association between heel height and gluteal muscle function and consensus opinion appears to support wearing a shoe that makes the person pay conscious attention to balance may in some cases improve deportment. Ironically this mirrors the function of the Buddha figure, not as a God Head, but a reminder to all, to be good.

    Walking is as we know a learned activity and very much influenced by social mores of the time. Deportment for ladies was a preoccupation of the Victorians who put enormous importance on such social etiquette. Learning to walk like a lady was part of school curriculum in finer schools and would have the same social significance as ‘keeping fit’ is today. The history of walking outside for ladies dates to the time of Queen Victoria and her love for roaming in the hills and glens surrounding Braemar, and her highland home at Balmoral. Heels in walking shoes for women were a novelty of the time and the heels then were positioned inferior to the arch of the foot. That particular design would mirror the negative heel style of today. During the thirties, shoe heels started to sit more posterior as the fashion for more functional footwear became the vogue. It took until the early fifties before the stiletto and almost at the end of the century before heels could sit inferior to the heel. These developments in heel design were made possible by acceptance of the shank in shoe construction and the availability of new polymer technology. The negative heel would seem to be a throwback to earlier times when straight flared shoes were the norm.

    What's new?

  12. W J Liggins

    W J Liggins Well-Known Member

    Excellent reply from Dave Smith 8th January.

    For our American readers I should point out that boll*cks are vulgar testicles, in the same way as Indian goolies, and simply b*lls.

    I agree with the comment!

  13. Envo2010

    Envo2010 Member

    Dear All

    Thanks for your comments. Regarding the point about there being no disclaimer for stilettos - in all fairness these are not marketed as Therapeutic shoes (unless for men), so no need for a disclaimer.

    These negative heeled shoes though are being marketed as being able to exert a therapeutic effect and in some examples are registered as medical devices. They are being promoted from what I can see as being able to actually help musculoskeletal problems with no downside.

    The patient was not running and the rupture was acute onset during walking in them. I have certainly seen cases of rupture with no more than walking in both men and women so I don't think increased activity is always to blame. There was no prior indication of Achilles Tendonopathy but she mentioned that she had been aware of general calf aching but put this down to the effect of the shoe working her muscles, so did not stop using them. This of course could have been the start of a repetitive strain subsequently misinterpreted as a positive effect, so ignored.

    Shoes specifically marketed as therapeutic shoes, should perhaps just indicate the potential problems that a user might experience and also state this in a way that the consumer can understand. In this case suggesting that users who have been used to generally wearing higher heels or have any pre-exisitng calf or Achilles injury should be aware that any calf / Achilles aching might be the start of an injury and not just a healthy exercise effect.


  14. CraigT

    CraigT Well-Known Member

    Dave- as always your posts blend science with common Podiatric sense. Good stuff.

    The ankle dorsiflexion may be due to being from a 'squatting' culture... ie they don't generally use toilets of the design you and I are used to. They squat. This needs pretty good dorsiflexion (and balance)... try it!
  15. Steve The Footman

    Steve The Footman Active Member

    I agree with Bob. If the shoes are being marketed for health benefits then they must be judged on a different level to fashion shoes.

    While it is easy to blame someone's weight and history of high heel shoes (not stated in this case), the reality is that negative heel shoes are inappropriate for most women in Western society. We do not have a history of barefoot walking so our gastroc-soleus complex is shortened. Wearing negative soled shoes will cause compensations that are likely to lead to injury including Achilles rupture.

    They make claims that are obviously false and erroneus. If nothing else they should be charged with false advertising.

    When the gynecologists start prescribing negative heeled shoes for fertility then I might start taking notice.
  16. Steve:

    Sorry, can't agree with you or Bob here. Would I say that the negative heeled shoes could have contributed to their Achilles tendon rupture? It is possible. However, her obesity, her use of higher heeled shoes over time, her activity level and any other ankle sprain could equally have caused the damage to the Achilles tendon that led to the rupture. How do you know that the shoes caused her injuries? What evidence do you have as such?

    Also, the more we, as a medical community, fall into the "blame game" of assuming that a company is responsible for a patient's problem and suggest to the patient that we think the company's product is responsible, then the more that attorneys will make all our lives miserable and more expensive by filing suit against these companies for cases such as this where there is no clear-cut evidence that the shoes did anything to harm the patient.

    What is the bottom line here? People need to take responsibility for their actions and not simply blame all their problems on the company that has the deepest pocket. If you lived in the USA, you would probably more readily understand how the development of this litigious attitude among the public has negatively affected our society as a whole.
  17. Steve The Footman

    Steve The Footman Active Member

    I agree wholeheartedly there. I think a lawsuit would be a waste of time and money even if it was successful. Not too far to go from suing a company for making crap shoes to suing podiatrists for their orthotic failures.

    What I think is needed is a government agency to intervene and stop these companies making such false claims. That should leave just the stupid ones who buy the products rather than the gullible.

    I still think there is a logical mechanism of action that the shoes caused the rupture - but how could you prove it? Undoubtably her weight and activity had something to do with it too.
  18. Asoke

    Asoke Welcome New Poster

    In my clinic I find Negetive heel roker shoes are highly beneficial for the patient with regular calf muscle cramp, tendon pain . Diabetic patient with claw toes are very safe with this shoe as during propulsion claw toes are not affected by reulceration.


    Asoke sengupta
    Sarathi's foot care
    Guwahati, Assam, India

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