High heeled shoes have maintained their popularity for centuries but are the visual benefits of wearing high heels worth the biomechanical detriment? What are the negative effects of wearing heels and can they make scoliosis worse?
One of the many factors we take into consideration when assessing a scoliosis patient is Activities of Daily Living or ADLs. These are the daily activities that patients perform at home, work and school that may have an impact on their posture and indirectly….their scoliosis. There are various things that can impact one’s ADLs and therefore affect posture. One such thing is the type of shoe you wear. But how could the type of shoe a patient wears affect their scoliosis?
Bottom-up Effect of Shoes (The toe bone is connected to the neck bone)
The shoes we wear can have a bottom-up effect, meaning if they affect the feet or ankles, that can affect the knees, which can affect the hips, which can affect the back. High-heeled shoes, specifically, have a long history of established harm. A recent study from Poland, wanted to test the harmful effects of wearing high-heeled shoes on the entire musculoskeletal system. They evaluated the electromyographic (EMG) activity of the main spinal muscles and pelvic mechanics of young and middle-aged women while they walked in low and high-heeled shoes.
31 young women (20-25 yrs) and 15 middle-aged women (45-55 yrs), with no prior back pain, were assessed while walking on a flat surface at natural speeds in three conditions: without shoes and in low-heeled (4 cm / 1.6 in) and in high-heeled (10 cm / 3.9 in) shoes.
In younger women, significant differences in electrical activity of the main spinal muscles were observed at initial ground contact as well as in Toe-off between the three conditions, with an increasing amount of muscle activation being observed with increased heel height. In middle-aged women, significantly higher lumbar activity was noted during high-heeled shoe use compared to without shoes. Interestingly, younger women exhibited an increase in pelvic range of motion during high-heeled use compared with low-heeled use and walking without shoes; however, this compensatory response was not observed in middle-aged women.
The authors suggest that increased low back muscle activity associated with wearing high-heeled shoes could aggravate muscle overuse and lead to low back problems. Also, they state that the lower pelvic range of motion associated with wearing high heels in middle-aged women may indicate that tissues in the low back and pelvic region become more rigid with age and that the harmful effect of high-heeled shoes on posture and spinal tissues may be more pronounced with advancing age. Meaning, you may not feel the effects of high heels while you are young, but–as with most things–it will catch up with you as you get older.
Forward Head Posture
One reason so many people continue to wear high heels, despite the obvious pain and other adverse effects, is the belief that they make one’s appearance more attractive. Many people claim that high heels improve their posture–that they stand straighter or taller as they are forced to balance in heels. If we take a look at the images below, the body does adjust to keep balanced, but not necessarily in the way most people would think.
Knee osteoarthritis is more common in women than men and is also a leading cause of disability. To identify the origin of this discrepancy, researchers observed 14 healthy females while they walked in 3.8 cm (1.5 in) flat athletic shoes, and 8.3 cm (3.3 in) heeled shoes with and without a 20% body weight vest. They found that at a typical walking speed:
- Knee flexion angle at heel-strike & midstance increased with increasing heel height & weight
- Maximum knee extension moment during loading response decreased with added weight
- Maximum knee extension moment during terminal stance decreased with heel height
- Maximum adduction moments increased with heel height.
Many of the changes observed with increasing heel height and weight were similar to those seen with aging and osteoarthritis progression. The researchers suggests that high heel use, especially when combined with increased weight, may contribute to increased risk of osteoarthritis (wear and tear on the joints) in women.
A similar study from 2014 also assessed the biomechanical role of osteoarthritis development and progression. Researchers collected data about participant’s self-reported footwear to assess specific shoe use per decade of life. With this they identified persistent users of certain footwear (i.e., heel height; sole thickness or hardness) from early adulthood.
They found that those who frequently wore women’s high-heeled and narrow heeled shoes during early adulthood displayed negative associations with both knee and hip osteoarthritis. Those who persistently wore narrow heeled shoes were associated with less risk of osteoarthritis. Further analysis suggested that women with hip osteoarthritis may have stopped wearing high and narrow heeled footwear to reduce hip pain in early adulthood.
Research from 2013 established a three-dimensional model of the “foot-ankle-shoe complex”. Heel strike, Midstance and Push-off (Toe-off) were simulated to assess the biomechanical response of high-heeled shoe walking.
They found that:
- Contact pressure at all metatarsophalangeal (MTP) joints intensified and reached their maximum at Toe-off
- The first metatarsophalangeal joint had the largest magnitude
- The first and fifth metatarsophalangeal joints had larger movements in transverse plane among all metatarsophalangeal joints, indicating that these two joints bended more significantly by toe box restraint during movement.
- The dorsal (top of foot) contact pressure at the first toe increased by four times from Heel strike to Toe-off
This study demonstrates the the intense amount of pressure and strain that walking in high-heels puts on the joints of the feet that leads to many different bone and joint ailments over time.
So Which is best? High, Medium or Flat Shoes?
As it turns out, high heels aren’t the only problem. A study from South Korean aimed to determine the most appropriate heel height for shoes by measuring the displacement of the center of pressure and changes in the distribution of foot pressure after walking in flat (0.5 cm / 0.2 in), middle-heeled (4 cm / 1.6 in), and high-heeled (9 cm / 3.5 in) shoes for 1 hour. 15 healthy women wore shoes with heels of each height in a random order. The foot pressure and displacement of center of pressure before and after walking in a typical setting for 1 hour were assessed. They found:
Both flat and high-heeled shoes had adverse effects on the body. Middle-heeled shoes (less than 2 in) are preferable to both flat shoes (less than 1 in) and high-heeled (3.5 in or larger) shoes for the health and comfort of the feet.
So Will Wearing High Heels Make Scoliosis Worse?
Though research consistently displays the negative effects of high heel use on posture and joint health, there has yet to be a study on how heels affect scoliosis. There has however been research indicating that spine alignment might affect the control of heel, ankle and toe rockers in the ankle-foot complex. When patients ask what they can personally do differently to help their scoliosis, based on these findings it’s safe to suggest that to decrease or eliminate high-heel use certainly can’t hurt.
However, one can understand that to ask a patient to completely do away with high heels might be asking too much, but to wear them everyday for 8 or more hours, I certainly would discourage that in ANYONE.
But is there any amount of research or data that can convince people to not wear heels or to at the very least decrease the frequency they wear them?
Medical History of High Heeled Shoe Use
An article published in 1998 from the University of Iowa explores the use of high heel shoes over their 400 year (and counting) reign and also details 250 years worth of literature from the medical community outlining the negative consequences of high heel use and the corresponding condemnation.
“For 250 years medical scientists have propagandized about the health hazards of high-heeled shoes, which originated four centuries ago. Physicians, however, largely unaware of their own profession’s tradition, keep reinventing the diagnostic wheel. This professional amnesia has held back the momentum of the process of educating the public. Consequently, despite these warnings, millions of women continue to wear high-heeled shoes.”
“If, instead of mistakenly believing that such shoes are 20th century creations, people understood that they have been worn for 400 years and that physicians during most of that time have been advising against their use, then perhaps the educational process would gain greater momentum.”
“The public health problem today is not that the causes of such injuries are not well known— the basic biomechanical causation has been fairly well understood for a long time—but that the lack of epidemiological studies has left conclusions about the long-term effects scientifically unproven. This lack of accumulated epidemiological evidence has been a major barrier to dissemination of the kind of dramatically persuasive information that has induced millions of people not to smoke tobacco.”