High heels and Women's Health
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Introduction[edit | edit source]
Although there is a perception that wearing high heels can increase a woman's attractiveness, they can change the biomechanics of walking and can affect gait by reducing stride length, and increasing pelvic tilt and hip rotation. 
A systematic review by Barnish et al (2018) found that with wearing high heels there are deviations to the neuromechanics of walking gait, and kinematics and kinetics of structures within the body, from the spine to the toes. This creates a risk for various conditions such as musculoskeletal pain, hallux valgus, ankle inversion injuries, and osteoarthritis. There can also be deviations in foot and ankle kinematics, kinetics, knee and hip flexion, gait, posture, and balance. Increased lumbar lordosis due to an increased pelvic tilt can be associated with the risk of low back pain. 
It is seen that the use of high heels in adolescents, individuals ranging from 10-19 years old, can lead to postural impairments, which effects head positioning, the back, pelvis, and the knees. Heel height and width are primary contributors to postural changes, and body imbalance. 
High heels are also seen to increase lumbar lordosis. They raise the Center of Mass (CoM), decreasing postural stability. It is interesting that there may be a heel height where the trunk muscles cannot adjust for ground reaction forces or CoM changes. Due to these changes, there is an adjusted increase in erector spinae activity, to maintain the deviated posture. The increased muscle activity can lead to increased discomfort and muscle fatigue. This would help explain the onset of low back pain in individuals who use high-heels for an extended period. It is found that the activity of trunk muscles increase as heel height increases, thus resulting in fatigue and discomfort of back muscles in women wearing high heels. 
Muscle Activation and Joint Loading during Gait[edit | edit source]
There are various muscles that have an altered activation with the use of high heels. The study by Simonsen et al (2012) made note of eight of these muscles. When women walked with a 9cm high heel, compared to barefoot, there was a difference in: 
- Doubling of the knee extensor moment peak in the first half of stance phase, likely due to the increased knee flexion and increased EMG in the quadriceps
- The knee extensor moment in midstance has a statistically significant difference to walking barefoot
- Pronounced and increased flexion of the knee during the first half of stance phase - the increased flexion of the knee joint is seen to produce an increased knee joint extensor moment.
- A marked increase in the knee joint abductor moment and the hip joint abductor moment, in the frontal plane
- There was an increase in knee extensor joint moment in midstance, while the hip joint moment remained unchanged
- A significantly increased external extensor moment at the knee joint, during midstance - with respect to internal muscle moments this represents a flexor moment.
- Higher ankle dorsiflexor moment after heel strike
- The reduction of the peak plantarflexor moment of the ankle join at push off
As a result of the increased knee joint extensor moment during walking with high heels, there are increased bone-on-bone forces in the knee joint. This may help explain the increase in the onset of knee osteoarthritis in women.
It is seen that there is an increased pressure distribution under the foot with the use of of high heels and with increasing heel height. 
There was an increased ankle angle with wearing and walking in high heels. As the ankle should, it was driven into a plantarflexed position at the end of stance. With high heels, the knee joint was also flexed more during heel strike and early stance. 
There was a decrease in the ankle joint moment with high-heel waking, compared to barefoot walking. This may be due to a decreased muscle fiber length and moment arm at the achilles tendon with a more plantarflexed position with barefoot walking. This reduction in net joint moment during push-off may be caused by the fact that the ankle is already plantarflexed, and there is less of a need for a large plantarflexor moment. 
Feel free to see Figure 5 in Simonsen et al 2012, for a comparison of EMG activity between barefoot and high-heeled walking for tibialis anterior, soleus, vastus lateralis, rectus femoris, biceps femoris, semimembranosus, and gemellus muscles. 
However, knee joint loading could be unchanged, in the sagittal plane, between barefoot walking and the use of high heels, since the extensor moment peaks during stance are unchanged between barefoot walking and with high heels. Though there was an increase in the external varus knee joint moment in the frontal plane. 
Other studies found a reduced internal ankle joint moment, an unchanged internal extensor knee joint moment in the sagittal plane, and a greater varus external knee joint moment in the frontal plane. The use of high heels do cause a greater varus and valgus moments at the knee joint, with the extensor moment at the knee joint remaining unchanged. 
Walking Speed[edit | edit source]
It is noted that walking speed may be 65% lower than generally normal walking speed when wearing high heels. 
The knee joint moment, as discussed above, is affected by walking speed. The knee joint moment, having an increased extensor dominance, is affected by the reduced ankle joint plantarflexor moment. 
It is interesting to note that gait velocities were not significantly different between young women and middle-aged women, and between the conditions of wearing no heels, low heels, and high heels. 
Conditions and Effects on Body Segments[edit | edit source]
Erector Spinae[edit | edit source]
The increased heel height produces an altered activation timing of the erector spinae muscles. A study showed that there was an early activation of the erector spinae muscles with the use of high heels. This goes to show that foot wedging can produce distinctive changes in the timing of muscle activation in the low back and pelvis, during gait. This may be clinically significant since an even short increase in EMG activity of the back muscles can lead to chronic overload and fatigue. 
A study measured the EMG of the erector spinae and pelvis kinematics, at normal walking speeds, of younger women and middle-aged women, in three conditions: without shoes, in low-heeled shoes (4cm), and high heeled shoes (10cm). It is seen that as heel height increases, erector spinae EMG activity increases. 
As can be seen throughout various studies, there are biomechanical differences according to the age range of individuals.  The lumbar spine absorbs and transmits the weight of the body. Differences are seen since the spinal column undergoes physical changes as individuals age. The curvature of women's spines gradually and moderately decrease from the late 20s to the 30s, with a decrease beginning thereafter. A second decrease in curvature begins once women reach 50 years. 
In younger women, within the three conditions of increasing heel height, there was an increased EMG activity recorded during gait at initial ground contact (heel strike) and at toe off. However, EMG activity did not differ much between wearing high heels and low heels. In addition, with high heels, there was a greater pelvic range of motion in the sagittal plane, compared to low heels and no heels. It is seen that younger individuals have a pronounced anterior pelvic tilt, and an increased spine lumbar lordosis. The increased lumbar lordosis, in younger women, does assist the spine in absorbing the increased vertical shock. However, this may lead to hyperlordosis with long-term use caused by changes in postural muscle activity. 
In middle aged women, there was a significantly higher lumbar erector spinae EMG activity between wearing high heels and with no heels. There was no significant difference between wearing low heels and no heels. They are seen to have a pronounced posterior pelvic tilt, and a reduced spine lordosis. With a posteriorly tilted pelvis, the hamstrings may become lax, which may lead to the loss of muscle tone in the hamstrings, and ongoing iliopsoas muscle activity, causing an anterior shift of the pelvis, and thus the hyperlordotic lumbar spine. 
Its interesting to note these differences since these changes in middle-aged women can increase soft tissue mechanical loading, which can facilitate degenerative changes. This can be noticed in those individuals with low back and knee concerns. The increased lumbar erector spinae EMG activity has the potential to cause muscle overuse, which could lead to low back problems. 
Here is a video to explain the effects on the erector spinae: 
Pelvis[edit | edit source]
The lower pelvic range of motion in middle aged women, compared to younger women, can signify that tissues in the lumbopelvic region become more rigid as one ages. Thus, the harmful effects of high heels on posture and spinal tissues may be more apparent with age. 
It is seen that changes in body tissue and structure due to ageing, such as worsening of tissue elasticity or tissue perfusion, alters the biomechanical adjustments brought on by wearing high heeled or stiletto type shoes. Thus, differences are noticed between young women and middle-aged women. 
Pelvic range of motion did not display a significant difference with heel height in the frontal or transverse planes, in both the young women and middle-aged women groups. However, the values were significantly lower in the middle-aged women group. In addition, heel height showed no significant effect on pelvic alignment angle, in both young and middle-aged women, in the sagittal, frontal, or transverse planes, during the initial contact and toe off phases of gait. Pelvic tilt angle, between young and middle-aged women, had no significant difference. 
Foot Deviations[edit | edit source]
The use of high heels does affect foot posture and alignment. This consists of the proper alignment of the bones and foot structure, thus any deviations in gait mechanics will alter the posture and affect the function of the foot. 
The use of high heels causes the foot to slide towards the front of the shoe, which results in squeezing/compression of the forefoot, especially since the front of the shoes are narrower than the foot. Since the hallux is squeezed towards eversion (inwards), in order to produce stability of the foot, the forefoot voluntarily moves in an adducted position. The increase in adduction indicates that there is increased foot supination. With this, there are a higher risk of overuse injuries (1). 
With the use of high heels, there is an increased pressure noticed at the first metatarsal, in which shear force, ground reaction force, and loading rate are increased. With the incredibly high force at the forefoot, the function of the foot is changed upon landing. 
The Oxford Foot Model is used to analyze the mechanical structure of the foot components such as the hallux, forefoot, and hindfoot. This model can help to understand the different characteristics of the flat foot during gait. With the use of high heels, it can be used to understand the mechanical deviations that are experienced by the foot. It is seen the movement of the forefoot and hind foot are very different than the normal foot. 
When measured in a series of 3 trials, in Wang et al (2016), with high heels of 5cm, it was seen that the use of high heels produced a greater hallux dorsiflexion in the last stance phase, and there was less hallux plantarflexion in the initial stance phase. 
The use of high heels produced a marked increase in forefoot abduction in late stance, compared to barefoot walking. However, the forefoot adduction angle was not significantly different. 
When analyzed in the horizontal plane, terminal stance with high heels showed a larger dorsiflexion angle, compared to barefoot walking. In contrary, there was no difference in plantarflexion. This may be adjusted by a longer time in amplitude of the ankle extensor moment, which would increase the load on the ankle, and would increase the risk of ankle injury.  It was seen by Healey and Chen (find reference in (7)) that the hallux was significantly increased for the hind foot to be elevated. This would cause shortening of the metatarsal fascia, which, due to the traction of the metatarsal fascia and the winch mechanism, causes the medial longitudinal arch of the foot to elevate. 
In the frontal plane, there was a greater angle of internal rotation, with high heels, in initial stance. There was also less extension rotation seen in midstance. There were no significant differences seen in the transverse plane. 
In the transverse plane, there was a higher forefoot abduction maximum range during late stance/toe off with high heels. 
The use of high heels produces a larger internal rotation. Since the talus connects to the hindfoot (heel) and the tibia, and internal rotation increases in the hindfoot, this may cause internal rotation of the tibia. Noting the coupling movement of the subtalar joint and the tibia, with the change in hindfoot motion, the movement of the tibia, and thus the function of the more proximal joints may be effected (26). 
It was noted by Simonsen et al ( ) (27) that the arches were raised when wearing high heels, and plantarflexion was greatly increased. In this case, ankle eversion would be restricted, and inversion to the hindfoot would be increased with any adjustments to motion. 
Hallux Valgus[edit | edit source]
Hallux valgus is a common foot deformity that occurs with the use of high heels. 
Hallux valgus is caused by adduction of the first metatarsal (21). Since forefoot adduction is markedly increased, the stress on the foot is proportionally changed.  It was found by Cavanagh et al (15) that the use of high heels, compared to barefoot waling, shifts a greater ground reaction force towards the metatarsal. Thus, there is a higher loading rate, shear force, and concentration of force. This change in force distribution is linked to hallux valgus (22). 
Dorsiflexion of the hallux causes the sesamoid to move distally. With this, the hallux dorsiflexion increases even more, which can lead to a sesamoid dislocation (20). The function of the sesamoid is to primarily limit eversion movement in the hallux, and attenuate any load bearing force in the first metatarsal head (19). 
Achilles Tendon Stiffness[edit | edit source]
It is mentioned by Cronin et al (24), that the achilles tendon force is increased with high heels, and results in achilles tendon stiffness. With the use of high heels there is a great increase in hindfoot dorsiflexion, which may disturb body balance and gait stability. This was adjusted by an increase achilles tendon stiffness. Contrarily, the achilles tendon stiffness could be caused by the loss of ankle joint range of motion (24). Thus, achilles pain and the risk of ankle sprain would be quite likely. 
Haglund's Syndrome[edit | edit source]
The use of high heels can cause Haglund's Deformity. The Physiopedia page on Haglund's Deformity nicely explains the impairment.
Gait Disturbances[edit | edit source]
Studies have shown that gait with high heels is less energy efficient, which can increase fatigue, reducing reflex and voluntary movement responses, in addition to changes in rate of muscle activation and strength. 
The use of high heel shoes aligns the foot in plantarflexion, which produces increased ground reaction forces that have an effect on the spine. Initial ground contact at the beginning of the gait cycle, induces a force caused by an increased ground reaction force, which is transmitted up the spine. This can pose as a danger of low back pain, as it relates to heel height. It is possible that loads absorbed by tissues during gait may further aggravate low back pain symptoms. However, the increased loads can in fact be dampened by alterations in the kinematics of the body, or through direct absorption by the soft tissues. 
Increased lumbar lordosis, which occurs with the use of high heeled shoes, has a purpose of absorbing the vertical loads. Thus, repetitive strain injuries can be caused by tissue overload that is not accommodated for in high heeled gait. 
Local muscle fatigue can be triggered by increased back muscle activity with high heeled gait. The accumulated muscle fatigue can lead to structural soft tissue impairments, such as swelling or restricted movement. In fact, this low intensity repetitive strain, at 2% of maximal load, of the lumbar muscles has been shown to reduce tissue oxygenation. Prolonged isometric muscle contraction at this intensity can also lead to repetitive strain injury in the lumbar region. Contrarily it is said that the chance of musculoskeletal injury can be reduced if the muscles can rest at levels below the 1-2% of maximal load. However, the fatigue can have an effect on the timing of lumbar muscle activation and lead to spinal tissue damage. Muscle fatigue and instability of the lumbar spine is seen to be a cause and effect of low back pain. Therefore, these microtrauma stresses that would occur to individuals who wear high heels for prolonged periods could lead to various deformities, impairments, and postural compensations. 
The use of high heels causes the body's CoM to move anteriorly and superiorly. This shift in the CoM may necessitate an earlier onset and greater activation of the erector spinae muscle activity to maintain balance and stability in the lumbopelvic region during gait. This increased contraction of the erector spinae muscles may cause an extension movement of the lumbar spine. This would lead to a posterior shift of the CoM balancing the anterior displacement caused by an increased heel height. 
Also, walking on harder surfaces causes an increased level of peak acceleration of ground reaction forces in the lumbar region.
Here is a video explaining the gait disturbances in reference to high heel usage: 
Osteoarthritis[edit | edit source]
A positive knee joint moment in the frontal plane, termed a valgus moment, may be crucial for joint deterioration due to osteoarthritis. When the knee joint is directed into a varus position, there will be an 'opening' of the lateral compartment, and the entire loading will be focused on the articular surfaces of the medial compartment. 
The knee joint abductor moment in the frontal plane was dominant with barefoot walking. This increased by 10% when wearing high heels, and showed a large increase in bone-on-bone forces. Since there is a 1% increase in knee joint abductor moment, this increases the risk of osteoarthritis progression by 6.46 times. 
Fertility and Pregnancy[edit | edit source]
Similar to an increased body mass index, pregnant women have an anteriorly tilted pelvis, due to their altered mass distribution. The adjustment for the shift in center of gravity from the increased body mass causes postural changes, which affect the position of the head, the neck, and the trunk. 
Offsetting the Negative Effects of High Heels[edit | edit source]
Evidence from a systematic review by Wang et al, shows that, 
- High heels at a height from 3.76 - 4.47cm are at a suitable heel height, with the optimal height for maintaining balance and stability being between 3-5cm.
- A larger heel base support increase stability during gait, decrease the chances of ankle injury, and provides more comfort while walking in high heels.
- Using a Total Contact Insert reduces pressure on the plantar surface of the foot, and therefore provides greater comfort.
Since there is a slight imbalance in the bodyweight distribution between the forefoot(43%) and hindfoot (57%), it is recommended by orthopedic specialists that wearing high heels at a height of 2cm can help balance the distribution of bodyweight exerted by the feet towards the ground. However, these findings are presented for the short-term, and the long-term effect is unclear. 
As mentioned above, there are three factors that can be adjusted to reduce the negative effects of high heels: heel height, Heel Base Support (HBS), and sole insert. In addition to kinematic and kinetic factors, the feeling of altered stability such as plantar pressure at a different aspect of the foot, deviations in Center of Pressure (CoP) during gait, and the rating of comfort. .... Two of the reviewed studies indicated that the most comfortable heel height for reduced gait disturbance, with an optimal heart rate, was 4.13cm +/- 0.34cm. Another study found the most comfortable heel height, by identifying the displacement of CoP, and changes in plantar pressure after waling for 1 hour. This study showed that a 4cm (compared to 0.5cm or 9cm) heel height had a stable CoP and less plantar pressure. 
Two studies considered HBS and the distribution of plantar pressure through the foot, CoP, and comfort. A large HBS was more beneficial compared to a small HBS as it produced a lower maximal peak pressure in each of the forefoot, midfoot, and rearfoot. In addition, a small HBS has an increased CoP deviation, when compared to a large HBS. Also, it is noted that a large HBS does provide more stability during gait. 
There were four studies that analysed insert insole on kinematics, kinetics, EMG, and comfort rating, with each study using a different type of insole. A study showed that the use of a Total Contact Insert (TCI) from the rearfoot to the metatarsal head can reduce peak MG by 19% and peak ES by 21.5%, with high heels at a height of 7.6cm, with a decreased rearfoot inversion angle. Another study showed that peak pressure in the medial forefoot was decreased with the use of TCI. It was seen to be more effective to use TCL in higher heeled shoes than lower heeled shoes or flats. 
It was noted by Luximon et al, that maximal peak pressure was increased over the entire plantar aspect with a large HBS, while with a narrow HBS there was a higher maximal peak pressure within the toe box . Gou et al, showed that the plantar pressure of the big toe was higher with small HBS, compared to being smaller with a larger HBS. The narrow HBS may be a causative factor of hammer toe, which is caused by increased pressure on the metatarsal-phalangeal region when using high heels. A smaller HBS led to gait instability, in which the toes have to grip the front of the shoe to gain stability. This creates a increased CoP shift for the individual, and can also lead to hammer toe. 
It is interesting to note that age, height, and BMI are important factors affecting the body when wearing high heels. This is because age would affect muscle strength and endurance, height can have an effect on joint moment, and bodyweight would effect the load going through the joints down to the foot. 
Resources[edit | edit source]
Here are some brief fun yet informative videos explaining the health effects of high heels, and where caution should be taken .
8 reasons not to wear high heels. 
This is a very technical video of the effects on the spine. 
Here is a video describing foot impairments or deformities that can occur with the use of high heels. 
References[edit | edit source]
- Prokop Pavol. High heels enhance perceived sexual attractiveness, leg length and women’s mate-guarding. Current Psychology. 2022:41:3282–3292.
- Barnish M, Morgan HM, Barnish J. The 2016 HIGh Heels: Health effects And psychosexual BenefITS (HIGH HABITS) study: systematic review of reviews and additional primary studies. BMC Public Health. 2018 Dec;18(1):1-3.
- Mika Anna, Oleksy Lukasz, Mika Poitr, Marchewka Anna, Clark Brian C. The Effect of Walking in High- and Low-Heeled Shoes on Erector Spinae Activity and Pelvis Kinematics During Gait. American Journal of Physical Medicine & Rehabilitation. 2012:91(5):425-434.
- Simonsen Erik B, Svendsen Morten B, Norreslet Andreas, Baldvinsson Henrik K, Heilskov-Hansen Thomas, Larsen Peter K, Alkjaer Tine, Henriksen Marius. Walking on High Heels Changes Muscle Activity and the Dynamics of Human Walking Significantly. Journal of Applied Biomechanics. 2012:28:20-28.
- Mesko Norbert, Ory Fanni, Csanyi Edit, Juhasz Lea, Szilagyi Greta, Lubics Oliver, Putz Adam, Lang Andras. Women Walk in High Heels: Lumbar Curvature, Dynamic Motion Stimuli and Attractiveness. International Journal of Environmental Research and Public Health. 2021:18 (299):1-10.
- AdvenrHealth Florida. How High Heels Affect Your Spine. Available from: https://www.youtube.com/watch?v=tcjXTGh145U&ab_channel=AdventHealthFlorida (accessed 19 January 2023).
- Wang Meizi, Gu Yaodong, Baker Julien Steven. Analysis of foot kinematics wearing high heels using the Oxford foot model. Technology and Health Care. 2018:26:815–823.
- Scholl. Wearing High Heels - Scholl Biomechanics. Available from: https://www.youtube.com/watch?v=xlnmvALaMZg&ab_channel=scholl (accessed 19 January 2023).
- Wang Meizi, Jiang Ci, Fekete Gusztav, Teo Ee-Chon, Gu Yaodong. Health View to Decrease Negative Effect of High Heels Wearing: A Systemic Review. Applied Bionics and Biomechanics. 2021:1-10.
- Grant the Foot Doc. The Unhealthy Effects of wearing high heels. Available from: https://www.youtube.com/watch?v=FnkJnHvpUTU&ab_channel=GranttheFootDoc (accessed 19 January 2023).
- Digital Minibar. MUST SEE! High Heels & it HARMFUL EFFECTS to the BODY. Available from: https://www.youtube.com/watch?v=Jf8dI6U-aIE&ab_channel=DigitalMimbar (accessed 19 January 2023).
- Insider Business. Negative Effects of Wearing High Heels. Available from: https://www.youtube.com/watch?v=5CGRmVl7jkY&ab_channel=InsiderBusiness https://www.youtube.com/watch?v=5CGRmVl7jkY&ab_channel=InsiderBusiness (accessed 19 January 2023).