LETTER
Reducing the frequency of wearing high-heeled shoes and increasing ankle strength can prevent ankle injury in women To the Editor: High-heeled shoes have become an essential part of women’s fashion and a requirement for some professions. However, the prolonged wearing of high-heeled shoes has been reported to increase load on the toes, to alter foot shape and gait patterns, to cause lordosis and back pain, and to shorten achilles tendons and stride length (1–3). Moreover, the prolonged wearing high heels may reduce the strengths of the plantarflexor (PF) and dorsiflexor (DF) of ankle joints (4,5). There have been numerous studies that have focused on the effects of wearing high heels on injuries related specifically to PF and DF (1–5). However, it was shown that the soft tissues around the ankle joints were affected by not only the PF and DF but also the invertor (IV) and evertor (EV) when wearing high heels. Specifically, we have seen that the IV and EV are much more susceptible to ankle injury than the PF and DF. For this reason, this study focused on the movements of four functional ankle muscles (PF, DF, IV, EV) and on related variables, such as balance by the dominant or non-dominant ankle joints. This study was conducted with 40 healthy collegiate women from the Department of Air Tourism and Service. They were required to
wear high-heeled shoes for their classes and thus consistently wore 10-cm high heels for more than three times per week. Participants were grouped according to their class year (from freshmen to senior). The ankle strength was isokinetically measured by a HUMAC/ NORMTM System and the dynamic balance was assessed using a HUMAC Balance System. The results from this study showed that the prolonged wearing of high-heeled shoes negatively affected the ankle strength of the IV and EV, in addition to the PF and DF. In other words, the prolonged wearing of highheeled shoes revealed the imbalances of four functional ankle muscles. In particular, the ankle strength of the IV and EV in the dominant and non-dominant sides showed a tendency to increase until the junior class and significantly decrease in the senior class (Table 1). These results suggest that wearing high heels may strengthen ankle muscles at first (1–3 years), but prolonged use (about 4 years) of high heels eventually causes a muscular imbalance, which is a crucial predictor of ankle injury. Moreover, due to the ankle muscular imbalance, the dynamic balance scores (Freshmen = 53.60 4.22; Sophomore = 53.90 5.40; Junior = 46.00
12.30; Senior = 32.30 7.50, respectively; p = 0.001) were considered to have had a negative influence over subsequent class years. Previous studies have shown that there are optimal ranges for DF/PF and EV/IV ratios, but also ranges in which injuries commonly occur. More specifically, increased DF/PF ratios and decreased EV/IV ratios at isokinetic 60°/s were reported in subjects with chronic ankle instability and weakened isokinetic ankle strength including the IV, EV and PF (6,7). Prolonged wearing of high heels apparently alters those ratios over subsequent class years by weakening certain ankle muscles which eventually compromises dynamic balance. As high heels are in fashion and sometimes required for certain professions, many women may be unaware of the extent to which it may be weakening their ankle strength and dynamic balance. Eventually, major accidents such as falls and serious ankle sprains can result without proper maintenance and conditioning. Therefore, it is clinically important for wearers of high heels to regularly perform ankle strengthening exercises, such as towel scrunches, heel walking, toe tappers and heel raises, and to limit the frequency of wearing high-heeled shoes as preventative measures.
Table 1 Comparative results of isokinetic four functional ankle muscles at 60°/s
Ankle muscles
Dorsiflexor (DF) (Nm) Dom Ndom Plantarflexor (PF) (Nm) Dom Ndom DF/PF ratio (%) Dom Ndom Evertor (EV) (Nm) Dom Ndom Invertor (IV) (Nm) Dom Ndom EV/IV ratio (%) Dom Ndom
Freshmen
Sophomore
Junior
Senior
p†
8.10 2.28 7.00 2.00
7.60 1.84 7.30 0.95
8.60 1.71 7.40 1.43
10.50 7.56 13.10 7.29
0.753 0.055
46.20 15.95 44.90 14.90
38.60 8.38 42.10 7.77
43.80 11.09 50.90 7.55
47.50 23.62 41.00 19.88
0.830 0.251
0.18 0.04 0.16 0.04
0.20 0.06 0.18 0.05
0.21 0.06 0.15 0.04
0.23 0.10 0.35 0.16
0.601 0.003**
8.00 2.26 9.10 1.45
14.70 2.41 14.60 2.72
17.30 4.76 16.50 3.14
8.00 2.83 8.90 2.28
0.001** 0.001**
11.00 3.09 12.30 2.41
17.70 3.95 16.90 3.03
19.00 4.22 21.10 5.11
12.20 8.89 15.60 8.68
0.001** 0.001**
0.78 0.28 0.76 0.17
0.85 0.17 0.89 0.22
0.94 0.29 0.80 0.12
0.83 0.31 0.66 0.21
0.604 0.125
All values are expressed as mean SD. Dom and Ndom represent dominant and non-dominant sides of ankle joint. †Results of Kruskal–Wallis test by nonparametric tests. **Represents p < 0.01.
ª 2015 John Wiley & Sons Ltd Int J Clin Pract, August 2015, 69, 8, 909–912
909
910
Letters
M.-H. Kim,1 Y.-T. Choi,1 Y.-S. Jee,1 D. Eun1 I.-G. Ko,2 S.-E. Kim,2 E.-S. Yi,3 J. Yoo,4 1 Exercise Physiology & Prescription, Graduate School of Health Promotion, Hanseo University, Seosan, Korea2Department of Physiology, College of Medicine, Kyung Hee University, Seoul, Korea3Exercise Rehabilitation & Welfare, College of Health Science, Gachon University, Incheon, Korea4Health Management, Sahmyook University, Seoul, Korea E-mail: [email protected]
References 1 Yung-Hui L, Wei-Hsien H. Effects of shoe inserts and heel height on foot pressure, impact force, and perceived comfort during walking. Appl Ergon 2005; 36: 355–62.
2 Tedeschi Filho W, Dezzotti NR, Joviliano EE, Moriya T, Piccinato CE. Influence of high-heeled shoes on venous function in young women. J Vasc Surg 2012; 56: 1039–44. 3 Silva AM, de Siqueira GR, da Silva GA. Implications of high-heeled shoes on body posture of adolescents. Rev Paul Pediatr 2013; 31: 265–71. 4 Csapo R, Maganaris CN, Seynnes OR, Narici MV. On muscle, tendon and high heels. J Exp Biol 2010; 213: 2582–8. 5 Cronin NJ, Barrett RS, Carty CP. Long-term use of high-heeled shoes alters the neuromechanics of human walking. J Appl Physiol 1985; 2012: 1054–8. 6 Abdel-aziem AA, Draz AH. Chronic ankle instability alters eccentric eversion/inversion and dorsiflexion/ plantarflexion ratio. J Back Musculoskelet Rehabil 2014; 27: 47–53.
7 Lee KY, Lee HJ, Kim SE, Choi PB, Song SH, Jee YS. Short term rehabilitation and ankle instability. Int J Sports Med 2012; 33: 485–96.
Acknowledgements This research was supported by the 2014 Hanseo University Research Grant.
Disclosure No potential conflict of interest relevant to this article was reported.
doi: 10.1111/ijcp.12684
LETTER
Erectile dysfunction and its detection in the healthcare setting: 10 years on To the Editor: Erectile dysfunction is considered an early indicator of cardiovascular disease. Jackson highlighted the important role that general practitioners and other healthcare professionals have in detecting erectile dysfunction and potentially preventing subsequent cardiovascular events (1). Nearly, a decade later and our results suggest that detection of erectile dysfunction remains poor. Cardiovascular disease costs the UK economy an estimated £29.1 billion annually and is responsible for 40% of all deaths (2). The prevalence of erectile dysfunction in those with or at risk of cardiovascular disease is reported to be as high as 75% (3). Both conditions share similar aetiologies and risk factors (4) and as a result, erectile dysfunction is typically experienced before the onset of a cardiac event. Erectile dysfunction is therefore regarded as a potential
early indication of underlying cardiovascular disease, where the mean time between developing erectile dysfunction and having a cardiovascular event is approximately 3 years (5). It has been reported that less than 25% of men seek help from a doctor in relation to erectile dysfunction. Contradictory to intuition however, less than 5% of men report embarrassment as a reason for not wanting to talk about sexual problems (6). General practitioners and primary care nurses report time pressures, lack of training and expertise, as well as concerns about the use of appropriate language as barriers to proactive engagement with patients in relation to sexual health issues (7). It has been recommended that men presenting in primary care with cardiovascular disease should be asked about erectile dysfunction (8). In addition, broaching the subject of erectile dysfunction with
Table 1 The severity of erectile dysfunction (ED) and help seeking for the condition
ED severity denoted by the IIEF-5
Number of participants by degree of severity, n (%)
Number of participants who had sought help for ED, n (%)
Severe Moderate Mild/Moderate Mild No ED Total
19 19 17 25 20 100
10 10 2 4 0 26
(19) (19) (17) (25) (20) (100)
(52.6) (52.6) (11.8) (16) (26)
men without any cardiac symptoms is also important as erectile dysfunction is considered an indication of increased cardiovascular disease risk (9). To ascertain the prevalence and severity of erectile dysfunction in a cohort of men attending an East London cardiac rehabilitation service, 100 men aged between 30 and 88 years (m = 56.82; SD = 10.48) completed the International Index of Erectile Function (10). Eighty per cent of respondents reported some degree of erectile dysfunction, of which 19% reported severe erectile dysfunction, 19% moderate, 17% mild-to-moderate and 25% mild (Table 1). Men on average had been suffering with erectile dysfunction for 2.8 years (SD = 3.32 years). Of the 80 men reporting erectile dysfunction, 65% had never spoken to a healthcare professional about their symptoms. Of those with moderate or severe erectile dysfunction; only 52.6% had spoken to a healthcare professional, while those with mild or mild to moderately severe erectile dysfunction; only 14.3% had done so (see Table 1). Only one individual was receiving treatment for erectile dysfunction. Jackson highlighted the important 2–3 year interval between experiencing erectile dysfunction and symptomatic coronary artery disease (1). He suggested that general practitioners and other healthcare professionals have a pivotal role to play in detecting erectile dysfunction early. Nearly a decade later, our results indicate that patients are still not receiving necessary medical help. Erectile dysfunction needs to be addressed in the healthª 2015 John Wiley & Sons Ltd Int J Clin Pract, August 2015, 69, 8, 909–912
Reducing the frequency of wearing high-heeled shoes and increasing ankle strength can prevent ankle injury in women To the Editor: High-heeled shoes have become an essential part of women’s fashion and a requirement for some professions. However, the prolonged wearing of high-heeled shoes has been reported to increase load on the toes, to alter foot shape and gait patterns, to cause lordosis and back pain, and to shorten achilles tendons and stride length (1–3). Moreover, the prolonged wearing high heels may reduce the strengths of the plantarflexor (PF) and dorsiflexor (DF) of ankle joints (4,5). There have been numerous studies that have focused on the effects of wearing high heels on injuries related specifically to PF and DF (1–5). However, it was shown that the soft tissues around the ankle joints were affected by not only the PF and DF but also the invertor (IV) and evertor (EV) when wearing high heels. Specifically, we have seen that the IV and EV are much more susceptible to ankle injury than the PF and DF. For this reason, this study focused on the movements of four functional ankle muscles (PF, DF, IV, EV) and on related variables, such as balance by the dominant or non-dominant ankle joints. This study was conducted with 40 healthy collegiate women from the Department of Air Tourism and Service. They were required to
wear high-heeled shoes for their classes and thus consistently wore 10-cm high heels for more than three times per week. Participants were grouped according to their class year (from freshmen to senior). The ankle strength was isokinetically measured by a HUMAC/ NORMTM System and the dynamic balance was assessed using a HUMAC Balance System. The results from this study showed that the prolonged wearing of high-heeled shoes negatively affected the ankle strength of the IV and EV, in addition to the PF and DF. In other words, the prolonged wearing of highheeled shoes revealed the imbalances of four functional ankle muscles. In particular, the ankle strength of the IV and EV in the dominant and non-dominant sides showed a tendency to increase until the junior class and significantly decrease in the senior class (Table 1). These results suggest that wearing high heels may strengthen ankle muscles at first (1–3 years), but prolonged use (about 4 years) of high heels eventually causes a muscular imbalance, which is a crucial predictor of ankle injury. Moreover, due to the ankle muscular imbalance, the dynamic balance scores (Freshmen = 53.60 4.22; Sophomore = 53.90 5.40; Junior = 46.00
12.30; Senior = 32.30 7.50, respectively; p = 0.001) were considered to have had a negative influence over subsequent class years. Previous studies have shown that there are optimal ranges for DF/PF and EV/IV ratios, but also ranges in which injuries commonly occur. More specifically, increased DF/PF ratios and decreased EV/IV ratios at isokinetic 60°/s were reported in subjects with chronic ankle instability and weakened isokinetic ankle strength including the IV, EV and PF (6,7). Prolonged wearing of high heels apparently alters those ratios over subsequent class years by weakening certain ankle muscles which eventually compromises dynamic balance. As high heels are in fashion and sometimes required for certain professions, many women may be unaware of the extent to which it may be weakening their ankle strength and dynamic balance. Eventually, major accidents such as falls and serious ankle sprains can result without proper maintenance and conditioning. Therefore, it is clinically important for wearers of high heels to regularly perform ankle strengthening exercises, such as towel scrunches, heel walking, toe tappers and heel raises, and to limit the frequency of wearing high-heeled shoes as preventative measures.
Table 1 Comparative results of isokinetic four functional ankle muscles at 60°/s
Ankle muscles
Dorsiflexor (DF) (Nm) Dom Ndom Plantarflexor (PF) (Nm) Dom Ndom DF/PF ratio (%) Dom Ndom Evertor (EV) (Nm) Dom Ndom Invertor (IV) (Nm) Dom Ndom EV/IV ratio (%) Dom Ndom
Freshmen
Sophomore
Junior
Senior
p†
8.10 2.28 7.00 2.00
7.60 1.84 7.30 0.95
8.60 1.71 7.40 1.43
10.50 7.56 13.10 7.29
0.753 0.055
46.20 15.95 44.90 14.90
38.60 8.38 42.10 7.77
43.80 11.09 50.90 7.55
47.50 23.62 41.00 19.88
0.830 0.251
0.18 0.04 0.16 0.04
0.20 0.06 0.18 0.05
0.21 0.06 0.15 0.04
0.23 0.10 0.35 0.16
0.601 0.003**
8.00 2.26 9.10 1.45
14.70 2.41 14.60 2.72
17.30 4.76 16.50 3.14
8.00 2.83 8.90 2.28
0.001** 0.001**
11.00 3.09 12.30 2.41
17.70 3.95 16.90 3.03
19.00 4.22 21.10 5.11
12.20 8.89 15.60 8.68
0.001** 0.001**
0.78 0.28 0.76 0.17
0.85 0.17 0.89 0.22
0.94 0.29 0.80 0.12
0.83 0.31 0.66 0.21
0.604 0.125
All values are expressed as mean SD. Dom and Ndom represent dominant and non-dominant sides of ankle joint. †Results of Kruskal–Wallis test by nonparametric tests. **Represents p < 0.01.
ª 2015 John Wiley & Sons Ltd Int J Clin Pract, August 2015, 69, 8, 909–912
909
910
Letters
M.-H. Kim,1 Y.-T. Choi,1 Y.-S. Jee,1 D. Eun1 I.-G. Ko,2 S.-E. Kim,2 E.-S. Yi,3 J. Yoo,4 1 Exercise Physiology & Prescription, Graduate School of Health Promotion, Hanseo University, Seosan, Korea2Department of Physiology, College of Medicine, Kyung Hee University, Seoul, Korea3Exercise Rehabilitation & Welfare, College of Health Science, Gachon University, Incheon, Korea4Health Management, Sahmyook University, Seoul, Korea E-mail: [email protected]
References 1 Yung-Hui L, Wei-Hsien H. Effects of shoe inserts and heel height on foot pressure, impact force, and perceived comfort during walking. Appl Ergon 2005; 36: 355–62.
2 Tedeschi Filho W, Dezzotti NR, Joviliano EE, Moriya T, Piccinato CE. Influence of high-heeled shoes on venous function in young women. J Vasc Surg 2012; 56: 1039–44. 3 Silva AM, de Siqueira GR, da Silva GA. Implications of high-heeled shoes on body posture of adolescents. Rev Paul Pediatr 2013; 31: 265–71. 4 Csapo R, Maganaris CN, Seynnes OR, Narici MV. On muscle, tendon and high heels. J Exp Biol 2010; 213: 2582–8. 5 Cronin NJ, Barrett RS, Carty CP. Long-term use of high-heeled shoes alters the neuromechanics of human walking. J Appl Physiol 1985; 2012: 1054–8. 6 Abdel-aziem AA, Draz AH. Chronic ankle instability alters eccentric eversion/inversion and dorsiflexion/ plantarflexion ratio. J Back Musculoskelet Rehabil 2014; 27: 47–53.
7 Lee KY, Lee HJ, Kim SE, Choi PB, Song SH, Jee YS. Short term rehabilitation and ankle instability. Int J Sports Med 2012; 33: 485–96.
Acknowledgements This research was supported by the 2014 Hanseo University Research Grant.
Disclosure No potential conflict of interest relevant to this article was reported.
doi: 10.1111/ijcp.12684
LETTER
Erectile dysfunction and its detection in the healthcare setting: 10 years on To the Editor: Erectile dysfunction is considered an early indicator of cardiovascular disease. Jackson highlighted the important role that general practitioners and other healthcare professionals have in detecting erectile dysfunction and potentially preventing subsequent cardiovascular events (1). Nearly, a decade later and our results suggest that detection of erectile dysfunction remains poor. Cardiovascular disease costs the UK economy an estimated £29.1 billion annually and is responsible for 40% of all deaths (2). The prevalence of erectile dysfunction in those with or at risk of cardiovascular disease is reported to be as high as 75% (3). Both conditions share similar aetiologies and risk factors (4) and as a result, erectile dysfunction is typically experienced before the onset of a cardiac event. Erectile dysfunction is therefore regarded as a potential
early indication of underlying cardiovascular disease, where the mean time between developing erectile dysfunction and having a cardiovascular event is approximately 3 years (5). It has been reported that less than 25% of men seek help from a doctor in relation to erectile dysfunction. Contradictory to intuition however, less than 5% of men report embarrassment as a reason for not wanting to talk about sexual problems (6). General practitioners and primary care nurses report time pressures, lack of training and expertise, as well as concerns about the use of appropriate language as barriers to proactive engagement with patients in relation to sexual health issues (7). It has been recommended that men presenting in primary care with cardiovascular disease should be asked about erectile dysfunction (8). In addition, broaching the subject of erectile dysfunction with
Table 1 The severity of erectile dysfunction (ED) and help seeking for the condition
ED severity denoted by the IIEF-5
Number of participants by degree of severity, n (%)
Number of participants who had sought help for ED, n (%)
Severe Moderate Mild/Moderate Mild No ED Total
19 19 17 25 20 100
10 10 2 4 0 26
(19) (19) (17) (25) (20) (100)
(52.6) (52.6) (11.8) (16) (26)
men without any cardiac symptoms is also important as erectile dysfunction is considered an indication of increased cardiovascular disease risk (9). To ascertain the prevalence and severity of erectile dysfunction in a cohort of men attending an East London cardiac rehabilitation service, 100 men aged between 30 and 88 years (m = 56.82; SD = 10.48) completed the International Index of Erectile Function (10). Eighty per cent of respondents reported some degree of erectile dysfunction, of which 19% reported severe erectile dysfunction, 19% moderate, 17% mild-to-moderate and 25% mild (Table 1). Men on average had been suffering with erectile dysfunction for 2.8 years (SD = 3.32 years). Of the 80 men reporting erectile dysfunction, 65% had never spoken to a healthcare professional about their symptoms. Of those with moderate or severe erectile dysfunction; only 52.6% had spoken to a healthcare professional, while those with mild or mild to moderately severe erectile dysfunction; only 14.3% had done so (see Table 1). Only one individual was receiving treatment for erectile dysfunction. Jackson highlighted the important 2–3 year interval between experiencing erectile dysfunction and symptomatic coronary artery disease (1). He suggested that general practitioners and other healthcare professionals have a pivotal role to play in detecting erectile dysfunction early. Nearly a decade later, our results indicate that patients are still not receiving necessary medical help. Erectile dysfunction needs to be addressed in the healthª 2015 John Wiley & Sons Ltd Int J Clin Pract, August 2015, 69, 8, 909–912
