How do high heels affect sagittal balance?

Impact of High Heels on Sagittal Balance

High heels negatively alter sagittal balance by increasing lumbar lordosis, creating an uneconomic body position, and potentially contributing to low back pain. 1

Biomechanical Changes with High Heels

• High heels significantly increase lumbar lordosis from an average of 54.3° to 65.2° when wearing high heels, particularly affecting the L4/L5 and L5/S1 disc angles 1
• Wearing high heels shifts the sagittal vertical axis (SVA) forward, from an average of 11.5mm to 29.8mm, indicating worse overall sagittal balance 1
• The higher the heel (especially above 45.5mm or approximately 1.8 inches), the greater the negative impact on sagittal balance 1
• High heels increase femoral obliquity angle by approximately 3°, knee flexion by 2.4°, and ankle flexion by 38.7° 2

Compensatory Mechanisms

• Individuals adapt to high heels through two primary mechanisms:
  • Lower extremity compensation: increased knee and ankle flexion 2
  • Spinal compensation: increased cervical lordosis, particularly in those who adapt with less-than-average knee flexion 2
• These different compensation patterns may explain why some high heel wearers experience neck pain while others develop knee or low back pain 2

Age-Related Differences in Adaptation

• Younger women (20-25 years) show increased pelvic range of motion in the sagittal plane when wearing high heels, which serves as a compensatory mechanism 3
• Middle-aged women (45-55 years) lack this compensatory response, suggesting that lumbopelvic tissues become more rigid with age 3
• The harmful effects of high heels on posture and spinal tissues may therefore be more pronounced with advancing age 3

Muscular Activity Changes

• High heels significantly increase lumbar erector spinae muscle activity during walking, particularly at initial ground contact and toe-off phases 3
• This increased muscle activity can lead to muscle overuse and fatigue, potentially contributing to low back problems 3
• The effect is observed in both young and middle-aged women, though the compensatory mechanisms differ 3

Contradictory Findings

• While most recent research indicates increased lumbar lordosis with high heels 1, some earlier studies have found decreased lumbar lordosis 4, 5
• One study specifically noted that high heels decreased lumbar lordosis in male subjects during dynamic activities, resulting in less swayback rather than more 5
• These contradictions may be due to differences in study methodology, participant characteristics, or the specific height of heels tested 5

Clinical Implications

• The altered sagittal balance from high heels creates an uneconomic body position that may explain why some women experience low back pain when wearing high-heeled shoes 1
• Appropriate footwear that provides comfort is generally recommended for maintaining proper biomechanical alignment 6
• For individuals with existing foot or back problems, properly fitting footwear that accommodates foot structure and provides adequate support is essential 6
• Healthcare professionals should consider the impact of footwear choices when evaluating patients with spinal alignment issues or back pain 1, 3

Risk Factors

• Heel height exceeding 45.5mm (approximately 1.8 inches) is strongly predictive of loss of static sagittal balance 1
• The negative effects of high heels appear to be more pronounced in middle-aged women compared to younger women 3
• Prolonged wearing of high heels may lead to chronic adaptations in posture and muscle activity that could contribute to persistent pain 3