This article has been inspired by a heated debate I had in the clinic this week. One of my patients, let’s call her “Shelly,” is hell bent on wearing high heels on a daily basis for work. When I recommended she trade her heels for a supportive sneaker, her initial response consisted of “But they look so good though!” After several minutes of going back and forth, she asked for SPECIFIC reasons why to avoid heels. Much to my dismay, I had very little concrete evidence and specific numbers to back up my standard response.

My standard response has always been that it can’t be great for your body to be in altered alignment due to the heel height. That vague response got me nowhere with Shelly. I had no answers for her follow up questions. How high is too high? How long can I wear them? What will it do to my back? As a 32-year-old male, my personal experience was limited, so I looked into the research to support my answers.

Hard, high-heeled, evidence

You may be surprised to find out that heels affect more than just your foot and ankle. Common complaints with high heels are foot and ankle pain, knee pain, and low back pain. Research has found that high heeled shoes can alter the normal mechanics in your legs and potentially lead to a lack of range of motion, balance deficits, and soft tissue injuries (1). The foot and ankle are the first part of your body to make contact with the ground during standing and walking, therefore altering your foot posture will a domino effect on your lower extremity and spine. In the picutre below (reference 6), you can easily see the changes your knees, hips, and back need to make to keep upright while wearing heeled shoes.

Let’s start from the ground up. Yes, your feet may hurt while wearing the shoes, however, prolonged heel wearing can lead to chronic issues later in life. A pilot study found that 80% of women between 50-70 years old had a foot problem. A third of those women had a problem that could potentially limit their mobility leading to a decreased quality of life (2). Also, the majority of ankle sprains (80 to 90%) occur when the foot and ankle are pointed down. That downward position is exactly how the ankle is placed while wearing heels, making it more likely to roll your ankle.

Moving up the chain, we come to the knee. We’ve all seen people walking with their knees bent because the heels are too high. High heels cause a greater compression between the knee cap (patella) and the thigh (femur.) This increased pressure can set you up for knee pain and potential osteoarthritis with long-term use (3). Lowering the heel height from 3.75 inches to 2.5 inches reduces the force at the kneecap by about 50%, suggesting that if a heel must be worn, a lower heel is safer (3).

Research has shown changes to foot alignment even affects the spine. High heels place the foot in a pointed down position, which changes the center of mass. Your body will inherently make compensations to maintain balance. The compensation at your spine is to accentuate the inward curve of your low back, thus causing strain on the lumbar spine (4). This increased lordosis causes compression of the lumbar spine, weakens your lower abdominal muscles, and reduces your hip flexibility. To add insult to injury, the altered position will change the timing and coordination between muscles in the upper body and spine; potentially lead to injury of the lumbar spine during functional tasks such as walking and reaching forward (5). That’s a hefty price to pay “Because they look good!”

Despite the aesthetic appeal of high heel shoes, you may be setting yourself up for injury to your foot, ankle, knee, or low back. Be judicious with the height and length of time in heels to lessen the possibility of injury. And remember, nothing looks better than an injury free body!

References
1. Moore JX, Lambert B, Jenkins GP, McGwin G. Epidemiology of High-Heel Shoe Injuries in U.S. Women:2002 to 2012. J Foot Ankle Surg. 2015;54:616-619.
2. Dawson J, Thorogood M, Marks SA, et al. The Prevalance of Foot Problems in Older Women: A Cause For Concern. J Public Health Med. 2002;24:77-84.
3. Foster A, Blanchette MG, Chou YC, Powers C. The Influence of Heel Height on Frontal Plane Ankle Biomechanics: Implications for Lateral Ankle Sprains. Foot Ankle Int. 2012;33:64-69.
4. Dai M, Li X, Zhou X, Hu Y, Luo Q, Zhou S. High-heeled-related Alteration in the Static Sagittal Profile of the Spino-pelvic Structure in Young Women. Eur Spine J. 2015;24:1274-1281.
5. Mika A, Clark B, Oleksy L. The Influence of High and Low Heeled Shoes on EMG Timing Characteristics of the Lumbar and Hip Extensor Complex During Trunk Forward Flexion and Return Task. Man Ther. 2013;18:506-511.
6. https://www.targetmassage.co.uk/blog/accompanied-pain/