• Tim Weitkunat, Florian M Buck, Thorsten Jentzsch, Hans-Peter Simmen, Clément M L Werner, and Georg Osterhoff.
• Division of Trauma Surgery, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
• Eur Spine J. 2016 Nov 1; 25 (11): 3658-3665.

PurposeWearing high heels is associated with chronic pain of the neck, lower back and knees. The mechanisms behind this have not been fully understood. The purpose of this study was to investigate the influence of high-heeled shoes on the sagittal balance of the spine and the whole body in non-habitual wearers of high heels.MethodsLateral standing whole body low-dose radiographs were obtained from 23 female participants (age 29 ± 6 years) with and without high heels and radiological parameters describing the sagittal balance were quantified. These were analyzed for differences between both conditions in the total sample and in subgroups.ResultsStanding in high heels was associated with an increased femoral obliquity angle [difference (Δ) 3.0° ± 1.7°, p < 0.0001], and increased knee (Δ 2.4° ± 2.9°, p = 0.0009) and ankle flexion (Δ 38.7° ± 3.4°, p < 0.0001). The differences in C7 and meatus vertical axis, cervical and lumbar lordosis, thoracic kyphosis, spino-sacral angle, pelvic tilt, sacral slope, and spinal tilt were not significant. Individuals adapting with less-than-average knee flexion responded to high heels by an additional increase in cervical lordosis (Δ 5.8° ± 10.7° vs. 1.8° ± 5.3°).ConclusionsIn all participants, wearing high heels led to increased flexion of the knees and to more ankle flexion. While some participants responded to high heels primarily through the lower extremities, others used increased cervical lordosis to adapt to the shift of the body's center of gravity. This could explain the different patterns of pain in the neck, lower back and knees seen in individuals wearing high heels frequently.

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