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Table 1 Results of included studies

From: The 2016 HIGh Heels: Health effects And psychosexual BenefITS (HIGH HABITS) study: systematic review of reviews and additional primary studies

Part A. Results of included reviews
Study Results
 Barnish and Barnisha, 2016 [21] Evidence from 18 studies was included (total sample size 14,647). Six studies (33%) were assessed as high quality, eight (44%) as moderate quality and four (22%) as low quality. Studies varied in terms of their populations, ranging from young women to the elderly, while others were whole-population studies including children. Three out of four studies found that high heels were associated with HV. Zero out of two studies found an association with OA. Three out of five studies found an association with MSK pain and this evidence was strengthened when study quality was taken into consideration. Seven out of eight studies found an association with first-party injury – two of these studies profiled emergency department presentations and found a considerable proportion of children among presenting cases. Only one study provided data on second-party injury and the reported injury toll was low. Generally, this review provides good epidemiological support for the idea that wearing high heels increases a woman’s risk of suffering MSK ill-health.
 Cowley et al., 2009 [25] Evidence from 38 publications is included. The body of evidence supports the view that high heels are associated with pain, HV and ankle inversion injuries. The majority of studies found alterations in foot and ankle kinematics, kinetics, knee and hip flexion, gait, posture and balance. Evidence for spinal alterations was less conclusive.
 Cronin, 2014 [22] Evidence from 43 publications is included. The body of evidence supports the view that wearing high heels leads to qualitatively consistent alterations to the neuromechanics of walking gait and the kinetics and kinematics of bodily structures from the toes to the spine in ways that may be seen as biomechanical markers of MSK conditions such as HV and OA.
 Murley et al.a, 2009 [24] Evidence from four studies on the effect of heel height was included. Most studies were on young adults. Generally, there was good evidence of alterations in lower limb and low back muscle activity, although one study found no significant difference.
 Riskowski et al., 2011 [26] Evidence from three studies on the effect of heel height is included. The single study on OA did not found an association with high heel wear. One of two studies on pain found an association.
 Russell, 2010 [27] Evidence from nine studies (one only available as a conference abstract) was included (total female sample size 182). Increased lumbar lordosis (potentially accompanied by increased pelvic tilt) would be expected to indicate increased risk of low back pain. This result was found in two out of nine studies, with a trend to an effect in younger female participants in one further study. The author argues for a disconnect between scientific evidence and Internet content/clinician opinion regarding the potential role of high heels in low back pain.
 Silva et al., 2013 [28] This could be considered a ‘semi-systematic’ review. Evidence from 20 studies fulfilling inclusion criteria, and 5 other studies, not fulfilling the criteria but considered useful, was included. This review focused on adolescents (aged 10 to 19). There was evidence that high heel wear in adolescents can lead to postural disorders affecting head positioning, the back, pelvis and knee. Heel height and width were identified as key factors in the emergency of postural changes and body imbalance.
Part B. Results for primary studies on psychosexual benefits associated with wearing high heels
 Guéguen, 2015 [20] Male participants were more likely to answer a survey on gender equality when the female confederate was wearing high heels than flat shoes (83% vs 47%). The difference between high and medium (63%) heels approached significance, but the difference between medium and flat was not significant. Male participants were more likely than female participants to answer a survey on food consumption habits presented by a female confederate. There was a significant effect of shoe condition for men (flat = 42%, medium = 60% and high heel = 82%), but not women (flat = 32%, medium = 37%, high = 30%). Male participants were more likely than female participants to help when a female confederate dropped a glove – there was a significant effect of shoe condition for men (flat = 62%, medium = 78% and high heel = 93%) but not for women (flat = 43%, medium = 50% and high 52%). Male participants were significantly more likely to approach a female confederate in a bar if she was wearing high heels than either medium (p = 0.02) or flat (p < 0.001) shoes – there was no significant difference between flat and medium (p = 0.26).
 Guéguen and Stefan, 2015 [37] Male participants were more likely to smile back at a female confederate if she was wearing high heels (56%) than medium heels (36%, p = 0.04) or flat shoes (30%, p < 0.01) – there was no significant difference between flat and medium (p = 0.52). Male participants were more likely than female participants to answer a survey on gender equality presented by a female confederate – there was a significant effect of shoe condition for men (flat = 48%, medium = 60%, high heel = 82%) but not women (flat = 42%, medium = 38%, high = 46%). Male participants’ judgements of a photograph of a young woman presented on a computer screen were influenced with regard to sexiness (p = 0.004), bust attractiveness (p < 0.001), overall attractiveness (p < 0.001), beauty (p = 0.01), desire to meet (p = 0.007) and attractiveness to other men (p < 0.01) depending on whether she was wearing flat shoes or high heels, even though the shoes were not shown in the photograph. There was no statistically significant effect on buttock attractiveness, probability of being in a couple, academic level, probability of having a child, expected dating acceptance, youth or age estimation.
 Guéguen et al., 2014 [38] Male participants’ judgements of a photograph of a young women presented on paper were influenced with regard to sexiness (p < 0.001), prettier legs (p < 0.001), prettier buttocks (p < 0.001), more elegance (p < 0.001), more good-looking (p < 0.001), youth (p < 0.001), being selected by others (p < 0.001) and being selected for an album (p < 0.001) depending on whether she was wearing flat shoes or high heels, even though the shoes were not shown in the photograph. These effects were all also found at p < 0.001 for female participants’ ratings.
 Maarouf, 2015 [38] When asked whether wearing high heels increased their attractiveness, 64% of surveyed businesswomen said yes, 27% said maybe and 9% said no. Among ‘worker’ women, 42% said yes, 45% said maybe and 13% said no. Among female university students, 66% said yes, 24% said maybe and 10% said no.
 Morris et al., 2013 [19] When assessing point-light displays of females walking, attractiveness index scores were higher in the high heel condition than the flat condition (p < 0.001). Female raters assessed the female walkers as being more attractive than male raters (p < 0.001). There was no statistically significant interaction between rater gender and shoe condition. Male and female raters were more accurate in correctly identifying female walkers as female when they were wearing high heels (p < 0.01). In this second experiment, raters were told there would also be male walkers, although in reality there were no males.
Part C. Description of case reports on second-party injury
Study Case description
 Ahmed, 1964 [29] Case 1: 31 year old man struck on the head with a stiletto heel after a fracas in a public house (a traditional type of bar in the UK). Radiograph revealed a small stellate depressed fracture to left parietal area with a small scalp laceration. Epileptic and dysphasic symptoms encountered. Patient recovered from operation and displayed no neurological abnormality at outpatient follow-up in February 1964, although abnormal EEG activity persisted in the left temporo-parietal area.
Case 2: 36 year old woman struck on the head by another women’s stiletto heel following a street fight. She suffered aphasia and right hemiplegia, with radiographs showing a depressed fracture in left parietal parasagittal area. Following operation, a gradual full recovery was experienced.
 Cleary et al., 2006 [30] Case: 16 year old female stepped on by stiletto heel of a fellow dancer on a dance floor. Penetration of right orbit, presented with headache and right eye pain. Seven months later, although visual acuity had improved, elevation and abduction were limited, with persisting ptosis. Surgery was planned to correct ocular position.
 Engelhart and Bliddal, 1997 [31] Case 1: 53 year old woman stepped on by another women’s high heels. Presented to doctor with oedema and pain, no fracture found on x-ray. Wound gradually healed after 4 months and pain slowly regressed.
Case 2: 50 year old women stepped on by another women’s high heels. Presented to doctor with oedema and pain, no fracture found on x-ray but infection suspected. Patient generally healthy at 6 month follow-up.
 Fry, 1959 [32] Case: 14 year old girl stepped on by another girl’s stiletto heel in a bus. Marked tenderness and swelling to the foot developed 2 days later and the girl could not use her foot. Penicillin was prescribed when no healing had taken place 10 days after. After five more days, improvement was noticed, but over 5 weeks after the injury, the girl was still having great difficulty walking. The clinician considered the girl fortunate not to suffer severed tendons.
 Jewsbury and Haslett, 2011 [33] Case: 43 year old woman stamped on the head with a stiletto heel. Presented appearing intoxicated but denied drinking or illicit drug use. After discharge, re-presented a month later with diplopia and headaches, mild dysphasia and irritability and ocular motility consistent with acquired Brown’s syndrome. Scans showed comminuted fracture of left medial orbital roof and cerebral laceration of left frontal lobe.
 Joyce and O’Shaughnessy, 2016 [34] Case: 22 year old woman stood on by another women’s stiletto heel at a bar. Swelling immediately encountered but minimal pain. On presentation, the hallux was grossly swollen with distal necrosis of the nailbed and pulp, accompanied by cellulitis. Skin graft operation was performed. Full healing was encountered.
 Missen, 1964 [35] Case: 54 year old man struck on the head with a stiletto heel by a female relative in a domestic fracas. Patient fell unconscious but was conscious on presentation to hospital. No neurological abnormalities were encountered. There was a scalp laceration in the right posterior parietal region. X-ray showed a deeply depressed bone fragment. An operation revealed a skull defect about 0.75 cm in diameter. The patient had recovered by discharge date and no further symptoms presented during a 1.5 year follow-up period.
 Stables et al., 2005 [36] Case: 23 year old man struck on side of head with a stiletto heel. Initially presented with a small wound and was discharged. He became increasingly unwell and encountered speech difficulties. Scans revealed minor depressed skull fracture of left parietal bone and underlying contusion of the parietal lobe. Upon arrival at neurosurgical unit, he presented with mild dysphasia which worsened. Symptoms presented consistent with cerebritis. Following craniectomy, he improved and the dysphasia had resolved at 12-month follow-up.
  1. asystematic review, HV hallux valgus, MSK musculoskeletal, OA osteoarthritis
  2. EEG electroencephalogram