High Heeled Shoes: History of the Trend, Risks and Honest Advice

Why do women wear high heeled shoes?  According to Smith and Helms, the tendency to wear high heels is motivated by a general psychological mechanism that drives women to engage in cultural practices that make them desirable to men (1).  High heeled shoes make women seemingly more appealing to men by shortening the calf, shortening the stride, lengthening the leg, toning the legs and making the foot appear smaller and thus more feminine.  There are various heights of heels and according to several high fashion shoe designers, a low heel is less than 2.5 inches, a mid heel is 2.5-3.5 inches and anything above 3.5 inches is considered a high heel.


Shoes date back to 3500 BC as depicted on Egyptian murals, however, at this time they were associated with the upper class.  Throughout the ages, heels have been worn by both men and women and have been associated with both upper class and lower class.  The heights have varied and styles have come in and out of vogue.  For the most part, however, women continue to consistently wear high-heels in spite of the pain and/or potential injury the shoes pose.


Thanks to a new fad, now infants can also enjoy high heeled shoes.  The heel itself is made of fabric and not intended to be walked on, thus they are indicated for infants who have not yet begun weight-bearing.  These are obviously just for looks and serve no function.


High heels for children are primarily for play and dress up.  They should not be worn while running and they should have a broad heel that is no more than 1 inch in height so as to reduce the risk of injury.  Ideally they are worn on flat surfaces only as children at this age do not have the necessary coordination to adapt to uneven surfaces in a heeled shoe.


Adolescence is usually the first time a girl wears heels.  At this time the heel should be 1-2 inches in height and worn for only short periods of time.  There is a condition that involves destruction of the growth plate of a metatarsal head called Frieberg’s disease that is associated with wearing high heeled shoes since they increase pressure in the ball of the foot (the metatarsal heads).  This can lead to permanent joint arthrosis and thus time spent in heels should be limited during the adolescent growth phase.  Frieberg’s is not always painful during the process but manifests as pain later in adulthood when the joint is completely broken down (3).


Adulthood is when most women spend the most time in heels.  Depending on the profession, some women wear high heels more than others.  A study in England did not find a correlation between profession (and shoes worn) with foot pain and/or deformity later in life.  The study did find, however, that women who wore heels throughout adulthood had an increased incidence of bunion deformity (4).  Stilettos and true “high” heels are better worn at this phase in life due to better coordination and balance.  However, these types of heels place significantly more pressure in the forefoot and lead to ball of foot pain.  Several companies now make flats that roll up so you can carry them in your purse to have available when your feet start hurting.  These should be utilized to minimize long-term damage to the foot, ankle and leg.


Balance and fall prevention is the main concern with shoe gear in the elderly.  As women age, it becomes more important to wear shoes with a heel no more than 1.5 inches high, a wider heel for more support, as many straps across the foot as possible, and a back to the heel.  A wedge-type shoe is always preferable for any age but especially in the elderly to better distribute pressure throughout the entire foot.  There are several brands of shoes that have a relatively low heel, a wider toe box and a platform sole that also accommodate orthotic inserts which is ideal for patients with foot deformities or balance issues.  Given that over 80% of elderly women have some form of foot deformity, this type of shoe clearly benefits most women.


The risk of high heels include fall, ankle sprain, ankle fracture, neuroma, bunions, hammertoes, metatarsalgia (ball of foot pain), blisters, corns, and calluses.  Several studies have also documented an increased load through the knee which can lead to increased incidence of knee osteoarthritis.  High heeled shoes also shift the center of gravity forward in the body which can lead to low back pain.  One study examined the effect on the Achilles tendon and found that long-term use of high-heeled shoes induces shortening of the calf muscle and increases Achilles tendon stiffness, reducing the ankle’s active range of motion (4).  When the Achilles tendon shortens over time then women actually have more pain in flat shoes and find themselves limited exclusively to heeled shoes for comfort.  A tight Achilles tendon can also cause plantar fasciitis which is very painful and can become chronic if not properly treated.


It is obvious that women will continue to wear high heeled shoes, even against the advice of medical professionals as they have done for hundreds of years.  In order to best avoid long-term complications of heel wear, it is best to limit time in heels to 2-3 hours at a time, limit heel height to less than 2 inches and wear heels only for special occasions.  Heels with material in the arch and around the heel provide more support.  For women who must wear heels for work then it is best to wear a walking shoe for commuting.  Daily stretching for the calf and Achilles will limit the amount of Achilles shortening over time and help prevent foot pain.



1 Smith EO, Helms WS.  Natural Selection and High Heels.  Foot & Ankle Int.  1999:  55-57.
2 Blitz NM, Yu JH.  Freiberg’s infraction in Identical Twins: A Case Report.  Foot & Ankle Surgery. 44 (3); 2005:  218-221.
3 Dawson J, Thorogood M, et al.  The prevalence of foot problems in older women: a cause for concern.  J Public Health Med. 24 (2); 2002:  77-84.
4 Csapo R, Maganaris CN, Seynnes OR, Narici MV. On muscle, tendon and high heels. J Exp Biol. 2010;213:2582-2588. doi:10.1242/jeb.044271.


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