The high-heeled shoe has been the center of controversy for hundreds of years.

The popular fashion favorite has pitted aesthetics against health, many have said.

Deformations such as hammer toes, bunions, Morton’s neuroma, Haglund’s and the shortening of the Achilles’ tendon have all been linked to wearing high heels, but correlation does not necessarily equal causation, some doctors say.

“It’s hard to say heels are the only cause for some of these problems,” said Dr. Matthew Dairman, founder of 1 Foot 2 Foot Centre for Foot and Ankle Care. “It can certainly attribute to them, but I see men with many of those same problems.”

Hammertoes can occur when the shoe requires the toes to bend. After a long period of time, it can cause the muscles to shorten, resulting in the deformity.

Often found in conjunction with hammertoes are bunions, which occur when the bone or tissue around the joint at the base of the big toe becomes enlarged.

People with foot deformities are at higher risk for developing Morton’s neuroma, caused by compression or irritation of the nerve between the third and fourth toes. It results in the thickening of the nerve and can lead to permanent nerve damage.

Haglund’s Deformity, a bony enlargement on the back of the heel that can painfully rub against a fluid filled sac between the tendon and the bone at the heel, is commonly known as “pump bump” because rigid backs of pump heels can create pressure and aggravate it.

All these deformities, however, can be ascribed not just to heels but to any number issues — from ill-fitting shoes to genetics.

Haglund’s can be caused by any shoe with a rigid back, from ice skates to men’s dress shoes, and “you don’t have to wear a heel to get a bunion,” Dairman said. “Anything that is too tight or too narrow can cause a multitude of problems, and in some cases it’s genetics. There are tribes of barefoot people in Africa who don’t wear shoes, and they still get bunions.”

While heels are often blamed for their problems, Dairman said one of the worst offenders is ballet flats.

“They’re narrow, crowd the toes, are more pointed, provide no support and are more likely to cause Hagland’s,” he said. “It’s a common misnomer that the flatter the shoe, the better it is. Heels somewhat support your arch and lock the foot in a better position to work as a rigid level for walking. Actually, one-to-two-inch heels are pretty good.”

A problem for which heels are more likely the culprit is the shortening of the Achilles tendon, at the back of the heel.

“The tendon will shorten up and contract,” Dairman said. “Women who wear heels really should be stretching that throughout the day.”

Pain and aesthetics are the two most common reasons people will seek medical help with foot deformities, but whether it’s your Achilles tendon or toes you’re worried about, there is a key to keeping both at bay.

“Moderation is key,” Dairman said. “You’ll never stop all the bunions in the world, but you can slow their progress. Wear heels a few hours at a time. Take them off and do exercises with your toes and stretch your Achilles tendon while you’re at your desk.”

Another effective way to keep deformities away is never to leave the store with a pair of shoes that are uncomfortable.

“My advice is don’t ever leave the store thinking you’ll break in a pair of shoes,” Dairman said. “The key to shoes is depth and width. You want them wide enough on the tops and sides so they don’t crowd the toes.”

Some women, Dairman knows, just love their heels. “You’re never going to talk out of her heels; remember moderation,” he suggested. “If you wear your four-inch heels one day, wear your sneakers the next day, if you can.”

In the end, whether you’re wearing heels or not, it’s not always possible to stop foot deformities, particularly when genetics is the main cause.

“If it doesn’t hurt, then don’t worry about it,” Dairman said. “If it does, you can slow it, and you can fix it surgically.”