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512 November/December 2009 • Vol 99 • No 6 • Journal of the American Podiatric Medical Association
Heel height is of importance to the podiatric physi-
cian in the contexts of pathology etiology, effects of
footwear, and orthotic therapy such as the applica-
tion of heel raises. Clinical assessment of the foot is
conducted with the patient barefoot while the most
common environment of the foot in the Western world
is in a shoe, often with a positive heel. Prescriptions
for foot orthotic devices are based on barefoot assess-
ments presumed to be translatable to the foot func-
tioning in a shoe.
This article explores relevant full-text literature to
reveal the effects of heel height on gait and posture
and the kinetics and kinematics of the foot, ankle,
knee, hip, and spine. Furthermore, special attention
will be given to the implications of increased heel
height for clinicians treating locomotor disorders
and provide information to aid clinical decision mak-
ing. Literature was accessed through Metalib (compris-
ing the databases of AMED, ASSIA, Blackwell Synergy,
BNI, Voyager, CINAHL, ScienceDirect, and Taylor
Francis full-text collection) using the keywords: high
heel, high heeled, raised heel, heel height, shoe, and
footwear. In the existing literature, the distinction be-
tween raised heel and high heel remains unclear. Al-
though the attempt to define these terms is beyond
the scope of the present review, clinical reports main-
ly use the term raised heels to define what is normal-
ly referred to as high heels. However, this is currently
being clarified.1Papers that focused on increased
heel height with reference to gait and posture were
selected.
Pathologies Associated with Increased
Heel Height
Clinical presentations of the foot associated with
wearing high-heeled shoes range from general dis-
comfort2, 3 to hallux valgus and plantar calluses.4
Shoes featuring high heels do, however, often have
common elements of design that could contribute to
the above conditions, such as narrow and shallow
toe box crushing the forefoot, cut-away uppers re-
ducing midfoot support, or weak or absent fasten-
ings allowing the foot to shift in the shoe.
The risk of ankle inversion injury has been shown
to relate to increased heel height,5which may con-
traindicate the use of heel raises in patients with a
history of lateral ankle sprains unless other ankle sta-
bilizing measures are used concurrently.
Foot and Ankle Kinematics
Various studies report that when the foot is posi-
tioned in a high-heeled shoe, several changes can be
observed.6-10 For instance, the ankle joint axis moves
anteriorly and the line of gravity moves posteriorly
toward the ankle joint.6, 8 More noticeably, the foot
This article explores relevant full-text literature to reveal the effects of heel height on
gait and posture and the kinetics and kinematics of the foot, ankle, knee, hip, and spine.
Furthermore, special attention will be given to the implications of increased heel height
for clinicians treating locomotor disorders and provide information to aid clinical decision
making. Full-text articles accessed from databases including AMED, ASSIA, Blackwell
Synergy, BNI, Voyager, CINAHL, ScienceDirect, and Taylor Francis inform the review. (J
Am Podiatr Med Assoc 99(6): 512-518, 2009)
*Faculty of Health, University of Plymouth, Plymouth,
United Kingdom.
†Faculty of Health, Staffordshire University, Stoke on
Trent, United Kingdom.
Corresponding author: Emma E. Cowley, MSc, Faculty
of Health, University of Plymouth, Derriford Rd, Plymouth,
Devon, PL6 8BH United Kingdom. (E-mail: emma.cowley
@plymouth.ac.uk)
The Effect of Heel Height on Gait and Posture
A Review of the Literature
Emma E. Cowley, MSc*
Thierry L. Chevalier, BSc†
Nachiappan Chockalingam, PhD†
BASIC SCIENCE REVIEW
Journal of the American Podiatric Medical Association • Vol 99 • No 6 • November/December 2009 513
becomes immediately shorter because of the arch ris-
ing.10 Ricci and Karpovich9studied women’s arch
height and found changes after a day wearing high
heels: heel heights of 0.6 to 2.1 cm resulted in an arch
height that was 0.3 cm lower; heel height of 6.2 to 7.1
cm resulted in an arch height that was 0.4 cm higher.
Moreover, Frey et al11 found that 86% of American
women wore shoes that were smaller than their feet,
possibly for reasons of reducing the space for foot
motion in the shoe. The inference from this evidence
is that if arch height increases because of high heels,
the foot will shorten, causing the shoe to become too
long for the foot, which would alter fit, comfort, and
stability. On the contrary, if the arch height is reduced
by wearing low-heeled shoes, the foot length will in-
crease when the shoes are worn, which potentially
could cause the foot to extend further into the shallow
distal end of the toe box. In another study, Schwartz
and Heath10 reported the immediate changes in foot
length with increased heel height. In agreement with
previous studies,9-11 it was observed that the heel-to-
ball length of the foot was reduced in high heels ac-
companied by increased arch height.
Broch et al12 reported that in high heels, the foot at-
tempts to slide distally in the shoe. Since the foot be-
comes shorter when wearing high-heeled shoes, it is
inevitable that the foot will slide forward, creating
compression between the vamp and the dorsum of the
foot. Such compression could be sufficient to elicit
pain in some feet. Prevention of this motion is normal-
ly achieved with substantial upper contact with the
foot and broad ankle fastenings, which unfortunately
are often missing in women’s high-heeled shoes.12, 13
Ebbeling et al7investigated lower-limb biomechan-
ics as a function of heel height. It was found that as
heel height increases, a graded increase in maximum
rearfoot eversion angle could be observed until the
highest heel condition (7.62 cm). In this heel height
condition, the angle reduces to less than that of a no-
heel elevation. However, the time taken to reach the
maximum rearfoot eversion angle is said to increase
linearly with heel height. This sudden reduction of
rearfoot eversion angle with 7.62-cm heel height could
be attributed to the increased work of the perimalleo-
lar muscles attempting to maintain stability of the
ankle joint.7This also has the indivertible effect of re-
ducing the available motion at the subtalar joint by
default of the perimalleolar muscles’ action. Ebbeling
et al7also postulated that a reduction in subtalar joint
eversion may be attributable to the peroneal muscles
having to work in tonic, isometric contraction to main-
tain stability of the plantarflexed ankle joint.
As previously mentioned, the risk of ankle inver-
sion injury has been shown to relate to increased heel
height.5In high-heeled shoes, the ankle joint has greater
freedom of frontal plane motion (and is therefore less
mechanically stable) because of the reduced articular
congruence between the talus and tibiofibular mor-
tice. This reduced articular congruence can be attrib-
uted to the plantarflexed position of the foot. Addi-
tionally, Payne et al14 found that feet with laterally
deviated subtalar joint axes, especially when com-
bined with a plantarflexed ankle joint, are at risk of
inversion ankle injury.14 Gollnick et al15 found an aver-
age of 20°ankle joint plantarflexion in subjects wear-
ing high-heeled shoes. This highlights the importance
of the musculoskeletal system having the capacity to
adapt to increased heel height. Ebbeling et al7also
found that the ankle joint is able to gain a dorsiflexed
position in the midstance phase of gait with heel
heights less than 7.62 cm. However, at 7.62 cm the
ankle does not recover from its plantarflexed position
even in swing phase emulating an equinus gait.15, 16
Although the vast majority of articles identified
kinematic changes caused by high heels, Hansen and
Childress17 determined that high-heeled shoes had no
significant effect on the ankle-foot rollover shape.
However, the authors indicated that the differences
could be seen with the use of very high heels (higher
than 5.0–6.0 cm). Furthermore, it is suggested that
the ankle cannot always fully compensate for the
foot’s unnatural position.17
In contrast to the studies mentioned above, the
use of heel raises or high-heeled shoes could also be
beneficial in treating specific pathologies. Cyriax18
postulated that heel elevation can decrease plantar
fascia strain. Recently, further cadaveric studies19 and
finite element modeling confirmed these findings. Ac-
cording to the latter,20 a heel height of 5.08 cm would
be beneficial in the treatment of plantar fasciitis.
Kogler et al19 also concluded that the inclusion of a
contoured, declined area of a shoe between the heel
and forefoot, along with a raised heel, reduced the
strain in the plantar fascia in some of the feet tested.
Kinetics
Perry et al21 conducted a study on running shoe com-
fort and concluded that increased pressure caused
by reduced contact area may contribute to pain. More-
over, Van der Leeden et al22 established a relationship
between joint damage and increased forefoot pressure.
In the same way, a reduction in weightbearing area in
high-heeled shoes can result in pain.23 So if the pos-
ture acquired when wearing high-heeled shoes places
demands on a joint or muscle beyond its capabilities,
it may increase the tissue’s stress to a point where in-
jury occurs.24 As a result, numerous studies3, 6, 8, 25-30
514 November/December 2009 • Vol 99 • No 6 • Journal of the American Podiatric Medical Association
have consistently demonstrated that high-heeled
shoes increase the maximum peak pressure, total
pressure, and duration of pressure under the medial
forefoot during gait. In addition, Yung-Hui and Wei-
Hsien3also demonstrated that the impact force dur-
ing gait will increase as a function of heel height.
Snow et al29 indicated that wearing high heels results
in higher overall pressures across the metatarsal
heads. However, it was suggested that additional
quantitative studies should be undertaken to assess
the long-term effects of wearing high-heeled shoes.3
Schwartz et al28 demonstrated that pressure under the
forefoot increased and heel pressure decreased at a
5-cm heel height. This suggests that there is an anteri-
or weight transfer mechanism occurring with the use
of high-heeled shoes. Soames and Clark30 concurred
with these findings, stating that mean pressure under
the first and second metatarsal heads were highest
and pressure under the lateral three metatarsal heads
decreased to zero as heel height increased. More re-
cently, Nyska et al27 confirmed these findings, indicat-
ing that the forefoot pressure not only increases but
transfers to the first metatarsal head while the lateral
forefoot unloads with increased heel height. In addi-
tion, the pressure increases under the first metatarsal
head double with the use of high-heeled shoes.13 It
was also found that the fifth metatarsal head un-
loaded before the end-of-stance phase with a shorter
force-time integral than the first metatarsal head.27
This would suggest that the weight transfer mecha-
nism happens not only in an anterior but also a medi-
al direction.
Furthermore, Nyska et al27 observed that the pres-
sure-time integral increased by 35% at the first metatar-
sal head as heel height increased. However, Gastwirth
et al25 performed an electrodynographic study of two
different heel heights and found an increase in dura-
tion of forefoot loading, but pressure did not increase.
Although the majority of evidence suggests that a
significant amount of weight is transferred to the fore-
foot when heel height is increased, some controversy
still remains with regard to increased forefoot pres-
sure.25 Furthermore, Yung-Hui and Wei-Hsien3estab-
lished that there are advantages to using shoe inserts
such as total contact insoles, even in high-heeled
shoes. The insert not only significantly reduces the im-
pact force, but also increases the perceived comfort.
This is an area that warrants further research.
As previously mentioned, when walking with high
heels of 7.62 cm or higher, the ankle cannot recover
from its plantarflexed position, even in the swing
phase. If the foot cannot achieve a plantigrade pos-
ture in gait, the pressure-time integral at the forefoot
will increase, and the rearfoot will unload by compar-
ison.15 A study by Özdemir et al31 indicated that al-
tered heel fat pad properties may contribute to heel
pain in barefoot gait and lead to antalgic changes in
gait pattern. An extrapolation of this finding could re-
late to the metatarsal fat pad with increased heel
height since the forefoot pressure-time integral in-
creases in high-heeled gait.16
In order to create tension prior to achieving a plan-
tarflexion motion, the triceps surae muscles have to
shorten concentrically, leaving a reduced range of
concentric contraction available for creating motion.32
This shortening of the triceps surae muscles will re-
sult in insufficient muscle shortening capacity to cre-
ate proper motion. As well as shortening the muscle
length, high heels will affect the lever arm of the tri-
ceps surae muscles by shortening it. This implies that
the muscles need to produce more force in order to
achieve the same moment of force. The Achilles ten-
don reduces tension as the ankle joint plantarflexes.6, 8
Since perimalleolar muscles can no longer produce
the same tension in high heels as when barefoot, con-
trol of the ankle, subtalar, and talonavicular joints is
compromised. Yet habitual high-heel wearers seem to
develop greater strength through range of ankle joint
plantarflexion,33 compensating for the loss of control.
It is anecdotally noted that the triceps surae contrac-
ture seen with chronic use of high heels34 is possibly
attributable to the triceps surae shortening after
many years of attempting to control the posture of a
high-heel wearer.
Electromyographic studies reveal further changes
provoked by wearing high heels. Basmajian and Bent-
zon35 discovered that the lateral head of the gastroc-
nemius muscle maintained constant contraction in
high heels (6 cm) compared with barefoot conditions.
Joseph36 added that tibialis anterior also increased its
activity with increased heel height, potentially con-
tributing to the stability of the ankle joint and reduc-
ing the pronation moment. Consequently, since tibialis
posterior, like the triceps surae, is similarly mechani-
cally compromised in this posture, overall instability
at the rearfoot is increased.
Stefanyshyn et al37 observed a decrease in ankle
joint plantarflexion moment, possibly attributable to
functional shortening as described above, but no
change in dorsiflexion moment as heel height in-
creased. In high heels of 8.5 cm, the need to create
plantarflexion motion is somewhat negated because
the foot is already in a plantarflexion position. The
issue is then to create sufficient tension to achieve
ankle joint stability by the plantarflexors.
A study by Esenyel et al38 focusing on kinetic pa-
rameters indicated a reduction in triceps surae muscle
moment, attributable to induced muscle weakness in
Journal of the American Podiatric Medical Association • Vol 99 • No 6 • November/December 2009 515
time. Although Kerrigan et al42 originally did not con-
trol heel height among their subjects, a more recent
study44 attempted to assess the effects of moderate
heel heights. It was found that wearing even a moder-
ately high-heeled shoe (3.8 cm) results in an increased
peak external varus knee moment in late stance as
well as an increased knee flexor moment of force in
the first half of the stance phase.44
A recent study37 reported a 23% increase in hip flex-
or work in response to a higher hip extension mo-
ment in high-heeled gait at preswing and swing phases
of gait. However, in loading response, the hip flexors
contribute negligibly to hip flexion since ground reac-
tion forces shift anterior to the hip joint. Likewise,
the reported 200% increase in knee extensor activity37
could be indirectly responsible for the reduction of
hip flexor moment.
Stefanyshyn et al37 also observed a 25% increase in
hip and knee varus moments in high-heeled gait. Esen-
yel et al38 demonstrated that the hip abductors showed
an 11% increase in work during stance phase, coun-
tering the hip varus moment created by high-heeled
gait. Another study35 focusing on muscle activity in
gait with increased heel height reported an additional
phase of activity of the gluteus medius muscle during
high-heeled gait. This may account for the findings of
reduced varus torque in some knees and hips,37 as the
gluteus medius could be resisting pelvic tilt (or drop)
in the frontal plane to a greater extent than in bare-
foot gait.
Spine
Opila-Correia45 compared experienced and inexperi-
enced wearers of high heels, postulating that there
would be a difference in the effect on posture be-
tween the two groups. This study is of particular in-
terest, since Opila et al46 noted that previous studies
had not taken into account the effects of habituation
when wearing high heels. Opila-Correia45 found that
immediate changes occurred as a result of wearing
high-heeled shoes: increased hip and knee flexion
and increased spinal lumbar lordosis in inexperi-
enced wearers of high heels. Furthermore, it was re-
ported that this change in lordosis was not evident in
experienced wearers, indicating the potential habitua-
tion in experienced wearers of high heels.
The influence of age on postural changes resulting
from prolonged use of shoes with increased heel
height has also been studied. A clinical perception47
that was initially confirmed48, 49 implies that wearing
high-heeled shoes increases lumbar lordosis. Opila-
Correia45 indicated that using high heels did result in
an increase in lumbar lordosis in younger subjects,
high heels. The study also reported a reduction in the
strength of triceps surae muscles by 29%. To overcome
the muscle weakness and plantarflexed ankle joint in-
stability, the gastrocnemius muscle tends to alter its
phasicity and becomes more tonic than phasic.35
Knee and Hip
Ebbeling et al7reported that the time taken for the
knee to reach maximum flexion in gait while wearing
high-heeled shoes was longer than that with no heel
inclination. Other studies have also found that the
knee does not achieve the same amount of flexion in
high-heeled shoes compared to low-heeled shoes.39, 40
Gehlsen et al39 studied the different effects of varying
heel height on knee activity during gait. It was found
that the mean values for knee flexion-extension dur-
ing the swing phase was significantly different and
decreased with high heels. However, this study pres-
ents a major methodological limit. The subjects with-
in the study wore their own high-heeled shoes and
the heel height parameter was not controlled, which
varied from 6.0 cm to 10.7 cm. Nonetheless, the re-
duced knee flexion induced by wearing high heels
will also result in a reduced amplitude sine wave pat-
tern of the center of mass, compared with that of
barefoot gait.40 With this reduced dampening action
of the knees, there is a potential for shock to travel
undampened up to the spine.
Since the gastrocnemius and the soleus have both
been reported to increase their tonic behavior in high-
heeled gait, it is possible that the phasic events sur-
rounding the popliteus muscle unlocking the knee in
the preswing phase of gait may be disrupted.41 With
the changes in triceps surae and perimalleolar muscle
activity and the timing of knee flexion plus rearfoot
eversion angle, Ebbeling et al7hypothesized that the
mechanism for knee unlocking that enables knee flex-
ion may be disrupted. This would then suggest that
the knee would be more injury-prone in high heels.
Additionally, in a study by Stefanyshyn et al,37 a 200%
increase in concentric knee extensor activity was ob-
served, compared to barefoot gait during this phase.
This considerable increase in moment of force, creat-
ed by the knee extensor muscles, counters the knee
flexion moment of force and therefore reduces the
amount of knee flexion during the swing phase in
high-heeled gait.
Kerrigan et al42 found parallel outcomes when
measuring the varus moment of force across the knee
in high-heeled shoes with a heel height higher than
5.0 cm, averaging 6.0 cm. It was suggested42, 43 that the
increase in varus moment could have destructive
consequences on knees subjected to such stress over
516 November/December 2009 • Vol 99 • No 6 • Journal of the American Podiatric Medical Association
but on the contrary, decreased in older subjects. Al-
though these findings add nuance to the earlier study
by stating that the effects of high heels on lumbar lor-
dosis are age dependent, some studies47, 50 found no
significant difference in average lumbar lordosis be-
tween heel heights (1.91, 3.81, 7.62 cm).
Lee et al51 found a 16°increase in spinal flexion be-
tween static and dynamic measurements in high-
heeled conditions. They showed that in gait, a 1°in-
crease in heel height results in a 1°decrease in lumbar
spinal flexion. A corresponding change in erector
spinae muscle activity accompanied the reduction in
flexion as the electromyogram signal at the fourth
and fifth lumbar vertebrae level was significantly high-
er with increased heel height in gait. On the other
hand, Joseph36 found no change in erector spinae ac-
tivity in women walking in low-elevated heels. Ac-
cording to a study by Bendix et al,52 the lumbar lordo-
sis and pelvic inclination was reduced with increased
heel height. However, the muscle activity remained
the same, unaffected by the change in heel height.
Gait, Posture, and Balance
The design of high-heeled shoes is highly variable,
ranging from platform to stiletto or tapered heel. A
study by Lord and Bashford53 demonstrated that pos-
tural stability in wearers of high-heeled shoes is im-
proved by increasing the area of the base of the heel.
A further study of high-heeled gait54 indicated that to
improve stability of the high-heel wearer, the center
of the heel should be medial, by 2 to 4 mm, to the
midline of the shoe. A recent study by Lindemann et
al33 reported no difference in the balance of octogenar-
ian women introduced to wearing 2-inch high-heeled
shoes. They compared these findings to women of the
same age who had time to habituate to the increased
heel height over a 5-week period. The study conclud-
ed that either no habituation was required or habitua-
tion took longer than 5 weeks in octogenarian women.
Similarly, no muscle contracture was reported in the
study, indicating that such change in this group may
take longer than 5 weeks.
Investigations by Lee et al51 into gait in high heels
demonstrated that stance phase time in high-heeled
gait increased when compared to low-heeled gait.
Furthermore, the subjects in high-heels walked more
slowly, had shorter strides and longer stance time
than when in low heels, while cadence remained un-
changed. In another study, Lee et al55 also indicated
that feet become more internally rotated, when com-
pared to the barefoot position in high heels than low
heels. Opila-Correia,45 however, found no change in
cadence, velocity, and percentage stance time relat-
ing to age.
In normal adult gait, the center of mass moves in a
way that produces a sine wave pattern that is indica-
tive of efficiency of gait with correct timing of gait
phases.56 High-heeled gait has been seen to disrupt
this ideal pattern as reported by Stefanyshyn et al,37
who noted how the acceleratory and deceleratory
forces increased in high heels resulting in loss of flu-
idity of gait, hence making gait less efficient. Accord-
ing to a recent study,45 in high-heeled shoes, subjects
aged between 23 and 42 years increased knee stabi-
lization using their quadriceps muscles.38
The postural changes caused by high heels is an
overall increase in stiffness of the kinetic chain, which
renders tissues more prone to injury from shock and
aberrant force vectors over time.42, 46 The risk of injury
increases further with a higher magnitude of vertical
ground reaction forces in high heels.7The increased
vertical ground reaction force and the loss of lumbar
lordosis increase the axial compression of interverte-
bral discs. These effects, combined with aging, imply
that the older population is more prone to back pain
and injuries. Additionally, the effects are amplified
with the more active erector spinae muscles, which
act in part to compress the spine.51
Other Effects of High Heels
Changes in gait with increased heel height have been
researched for many years, with recent studies using
complex kinematic, kinetic, and physiologic tech-
niques.7, 38 Mathews and Wooten57 found that oxygen
consumption increases when walking in high-heeled
shoes. Studies by Mathews and Wooten57 and Ebbel-
ing et al7revealed that high-heeled gait is more energy
consuming than low-heeled gait and can lead to fatigue,
which reduces reflex and voluntary response rates as
well as affecting muscle phasicity and strength.58
Interestingly, Ebbeling et al7found no significant
differences for any kinematic parameters between
experienced (and, therefore, possibly contractured)
and inexperienced wearers of high heels, a finding
contradicted in a study by Kuni and Schmitt.59
Conclusions
This review has illustrated the effects of increased heel
height on a normal adult population. Considerations
for clinicians from this review include acknowledg-
ment of the effects, both beneficial and detrimental,
of increased heel height in the context of pathology
or impaired function.
Journal of the American Podiatric Medical Association • Vol 99 • No 6 • November/December 2009 517
Financial Disclosure: None reported.
Conflict of Interest: None reported.
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