By Erika Kruger

Photographs; Martin Van Niekerk, Shufti Pics

Summer is here and so are patients arriving at the massage practice wearing flip-flops or in local parlance, the all-time popular plakkies.

People’s views on this form of footwear flip-flops between near veneration by wearers  (‘It is so comfortable and easy to wear – absolute freedom!’) and health professionals blaming overuse of the plakkies for a host of podiatric problems and postural imbalances.

Personal observation has led me to conclude that patients’ complain of pain in the feet and in the lower legs more often in the summer months than during winter. Questions about their preferred footwear, usually indicate extensive use of plakkies. Despite claims that it feels just like walking barefoot, flip-flops might not be a healthy choice after all. A study conducted by a doctoral student in biomechanics at the University of Auburn, Alabama, confirms this. 1)

Justin Shroyer started his investigations into a possible link between wearing flip-flops and lower leg and foot pain, by observing 39 college-age female and male volunteers wearing thong-style, flat-soled flip-flops and then regular athletic shoes while walking on a platform that measured the force they exerted when their feet struck the ground. He also filmed them as they walked to study differences in the movements of their hips, legs, knees, ankles, feet and toes. The visual and other data was then digitised and analysed.

Shroyer’s conclusions confirmed that despite the freedom and comfort wearers profess, plakkies first of all do not provide enough stability for the foot and secondly can lead to postural imbalances resulting in back ache. 2)

SHOCK ABSORPTION

Flip-flops provide little support and shock absorption, and as a result, they provide little comfort and protection against the impact from walking. Without suitable cushioning on the feet, over time the impact will cause pain in sensitive areas of the back and spine, particularly in the discs, joints and ligaments. 3)

STABILITY

Physiatrist Dr Chritina Lasich explains that a shoe has everything to do with how ones back feels. 4) She compares shoes to tires – both “provide for your comfort (ride quality), your stability (support), and your posture (alignment). Shoes form the foundation of the body.”

According to the American Podiatric Medical Association (APMA) flip-flops do not fit any of these requirements – it doesn’t provide any arch support, heel protection or shock absorption and causes problems like tendonitis, arch-pain and sprained ankles. 5) The problem is that flip-flops “don’t really hold on the foot like most shoes do, so we use the tendons and muscles to hold them on,” says Dr. Greg Cohen, a podiatrist at Long Island College Hospital in Brooklyn, N.Y. 6) Unlike a good shoe that always controls the heel with a strap or a cup, flip-flops offer none of these stabilizing forces that provide a solid foundation for the entire limb and spine. 7) They can also stretch the calf muscle causing strain on the Achilles tendon. This may become a chronic condition such as inflammation of the Achilles tendons and plantar fasciitis (see page 7).

The characteristic flip-flop shuffle that Shoyer describes as “an unnatural, toe-gripping, foot-slapping gait” 8) also causes conditions such as hammertoes (See page 6), joint pain and tendonitis. He speculates that people wearing plakkies could run a higher risk of muscle and joint pain in the legs as “(t)here’s a larger angle in your ankle in flip-flops, … because people are gripping with their toes so the flip-flop won’t fly off. … So you’ve got this battle going on between muscles on top and on the bottom.” 9) That constant pressure also often adds up to throbbing and tenderness in the toes.

POSTURE

As a therapeutic massage therapist is well aware, the position of the foot affects the position of the ankles, knees, hips and spine, and as a result, the entire kinetic chain of the human body. Starting with the feet, apart from using the toes as claws, flip-flops also causes the foot to pronate. According to Dr. John E. Mancuso a podiatrist at the Manhattan Podiatry Associates in New York the spongy soles allows the foot, which naturally roles inward as the foot hits the ground, to roll even more than usual. 10)

“Each time a foot pounds the ground, the arch is supposed to be locked to absorb shock, he explains. ”But during pronation, the arch opens and releases this locking mechanism, leading to problems such as pain in the heel, the arch, the toes and in the forefoot.” 11)

SPINAL CURVATURE ADJUSTMENTS

Wearing flip-flops can unnaturally adjust the spine into the wrong alignment and alter the important curves of the spine. This leads to uneven wear on the discs, joints and ligaments in the spine, causing back pain and a variety of postural misalignments and problems maintaining balance. 12) 13) Any existing postural abnormality or biomechanical problem is further aggravated through the overuse of flip-flops.

GAIT

Shroyer’s study also compared flip-flop wearing against that of athletic shoes. He concludes that there is a distinct change of gait among flip-flop wearers as a result of the strain on the arch, ankle, even the hips and lower back. He also found that flip-flop wearers:

  • took shorter steps14)
  • didn’t lift their toes as much as their legs swung forward probably because they were using their toes to grip the flip-flops  to keep them from falling off and
  • didn’t bring feet up normally while walking 15)

“The result is more stress on the body because you have to move more to go the same distance as people wearing other kinds of shoes,” he explains 16). As walking is a very repetitive motion, if you walk a lot, those little changes to your posture could increase exponentially 17).

OTHER EFFECTS

Wearing flip-flops may also lead to:

  • Foot injuries – As the foot is exposed, the risk of cutting the foot or it being stood on is increased and many people suffer from cuts, bruising and injuries to toe nails from wearing them  18).
  • Ankle sprains – As flip-flops provide little stability, tripping is also common, which can lead to sprains from falling over 19).
  • Nerve pain
  • Heel calluses (from the pounding) 20)
  • Irritation between the toes (from the toe thongs), which can lead to nasty fungal infections 21).

CONCLUSION

“Flip-flops were never meant to be everyday shoes,” says Dr. Marybeth Crane, a sports podiatrist and spokeswoman for the American College of Foot and Ankle Surgeons 22). It is fine for wearing to the beach or around the pool but the massage therapist would be remiss if he/she did not educate their flip-flop wearing patients about the biomechanical problems that might result from overuse.

References

  1. Auburn University . AU study shows that overuse of flip-flops can lead to orthopaedic problems http://wireeagle.auburn.edu/news/359Ibid
  2. Mobilis Direct-website https://www.mobilisdirect.com/story-1107-wearing-flip-flops-can-cause-back-problems.aspx?year=2008
  3. Ibid.
  4. Lasich, C. High Heels and Flip-Flops Cause Back Pain. Spine Universe http://www.spineuniverse.com/article/back-pain-high-heels-flip-flops-4390.html
  5. Balais, M Wearing flip-flops can lead to future health problems. Alachua Post http://alachuapost.com/All/4205.html?25
  6. Yara, S. (2006) Skip the flip-flops. Forbes.com  http://www.forbes.com/2006/05/03/flipflop-foot-problems_cx_sy_0504htow.html
  7. Lasich, C. High Heels and Flip-Flops Cause Back Pain. Spine Universe
  8. Auburn University . AU study shows that overuse of flip-flops can lead to orthopaedic problems
  9. Mcmanis, S Why podiatrists can’t support the flip-flop fashion http://www.reporternews.com/news/2008/jul/21/why-podiatrists-cant-support-the-flip-flop/?printer=1/
  10. Yara, S. (2006) Skip the flip-flops. Forbes.com
  11. Ibid.
  12. Mobilis Direct-website
  13. Balais, M Wearing flip-flops can lead to future health problems. Alachua Post
  14. Auburn University . AU study shows that overuse of flip-flops can lead to orthopaedic problems
  15. Mcmanis, S Why podiatrists can’t support the flip-flop fashion
  16. Auburn University . AU study shows that overuse of flip-flops can lead to orthopaedic problems
  17. Mcmanis, S Why podiatrists can’t support the flip-flop fashion
  18. Mobilis Direct-website
  19. Mobilis Direct-website
  20. Smith, L. Jr., Trouble afoot with flip-flops. Today. http://www.usatoday.com/news/health/painter/2007-07-01-flip-flops-trouble_N.htm
  21. Ibid.
  22. Ibid.