Background
Walking with high-heeled shoes is a common cause of venous complaints such as pain, fatigue, and heavy-feeling legs. The aim of the study was to clarify the influence of high-heeled shoes on the venous return and test the hypothesis that women wearing different styles of high-heeled shoes present an impaired venous return when compared with their values when they are barefoot.
Methods
Thirty asymptomatic women (mean age, 26.4 years) wearing appropriately sized shoes were evaluated by air plethysmography (APG), a test that measures changes in air volume on a cuff placed on the calf, while they performed orthostatic flexion and extension foot movements and altered standing up and lying down. The test was repeated in four situations: barefoot (0 cm), medium heels (3.5 cm), stiletto high heels (7 cm), and platform high heels (7 cm). The APG values of venous filling index (VFI), ejection fraction (EF), and residual volume fraction (RVF) were divided into four groups according to heel height and compared by repeated-measures analysis of variance.
Results
RVF was increased in the groups wearing high heels (stiletto and platform) compared with the barefoot group (P < .05). RVF was increased in the medium-heel group (3.5 cm) compared with the barefoot group (P < .05), and despite the lack of statistical significance, the medium-heel group showed lower values of RVF compared with the two high-heel groups. The EF parameter followed the opposite tendency, showing higher values for the barefoot group compared with the other three groups (P < .05). Values for VFI were similar in the three situations evaluated.
Conclusions
High heels reduce muscle pump function, as demonstrated by reduced EF and increased RVF values. The continuous use of high heels tends to provoke venous hypertension in the lower limbs and may represent a causal factor of venous disease symptoms.

Figures and tables from this article:

Fig 1. A, A volunteer resting in the air plethysmography examination room. B, The air plethysmography cuff has been applied to the volunteer's left leg during calibration. C, Registering venous filling with the volunteer standing barefooted. D, Tiptoe movements contracting the calf. E, Volunteer using device support for better calf relaxing after acquiring ejection volume wearing a 7-cm high-heeled shoe. Volunteer lifting and contracting calf with the three different heels studied: (F) 3.5 high-heeled shoes, (G) 7-cm high-heeled stiletto shoes, and (H) 7-cm high-heeled platform shoes.
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Fig 2. Three kinds of heels were studied: (A) 7-cm high-heeled stiletto shoe, (B) 7-cm high-heeled platform shoe, and (C) 3.5-cm high-heeled shoe.
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Fig 3. The venous filling index (VFI) is shown according to the kind of heel. There was no statistical difference among the VFI values with the heel variations (P > .05). The horizontal line in the middle of each box indicates the median; the top and bottom borders of the box mark the 75th and 25th percentiles, respectively, and the whiskers mark the 90th and 10th percentiles.
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Fig 4. The ejection fraction (EF) is shown according to the kind of heel. Greater values in the EF parameter were found with barefooted group compared with 7-cm stiletto and 7-cm platform high-heeled shoes. The letters a and b indicate statistically significant differences (P < .05). The horizontal line in the middle of each box indicates the median; the top and bottom borders of the box mark the 75th and 25th percentiles, respectively, and the whiskers mark the 90th and 10th percentiles.
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Fig 5. The residual volume fraction (RVF) is shown according to the kind of heel: Greater values in the RVF parameter were found with the 7-cm stiletto and platform shoes. The letters a and b indicate statistically significant differences (P < .05). The horizontal line in the middle of each box indicates the median; the top and bottom borders of the box mark the 75th and 25th percentiles, respectively, and the whiskers mark the 90th and 10th percentiles.
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Fig 6. Means of the parameters venous filling index (VFI), ejection fraction (EF), and residual volume fraction (RVF) are displayed according to the four situations tested: barefooted, wearing a 3.5-cm high-heeled shoe, a 7-cm high-heeled stiletto shoe, and a 7-cm high-heeled platform shoe. The bars represent mean data. +, ++, *, and ** indicate a statistically significant difference (P < .05).
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Table. Venous function parameters in each one of the four situations

EF, Ejection fraction; RVF, residual volume fraction; SD, standard deviation; VFI, venous filling index.

Fig 4. The ejection fraction (EF) is shown according to the kind of heel. Greater values in the EF parameter were found with barefooted group compared with 7-cm stiletto and 7-cm platform high-heeled shoes. The letters a and b indicate statistically significant differences (P < .05). The horizontal line in the middle of each box indicates the median; the top and bottom borders of the box mark the 75th and 25th percentiles, respectively, and the whiskers mark the 90th and 10th percentiles.
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This study received financial support from Fundação de Apoio à Pesquisa do Estado de São Paulo, São Paulo, Brazil.
Author conflict of interest: none.
The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.

Reprint requests: Wagner Tedeschi Filho, Rua: Caingangs, 1380 Parque Universitário, 17607-321 Tupã–SP, Brasil
Copyright © 2012 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.