Moreover, the potential for high heels to inflict injury both on the wearer and on bystanders should be considered. For example, Williams and Haines18 identified 240 emergency department (ED) presentations over a 5-year period in the Australian state of Victoria resulting from first-party injury from high heels and a further 65 resulting from second-party injury from high heels. Since pressure is inversely associated with the cross-sectional area through which a force is applied,19 the potential for high heel shoe wearing to result in injury to both the wearer and on bystanders should be considered. Such shoes are exempt from restrictions on wear in public places and age restrictions on sale that are imposed on other sharp bladed objects such as knives in countries such as the UK20 and Australia.21
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Chaiklieng and Suggaravetsiri35 found a significant association between use of high heels and repetitive strain injury in teachers (OR=1.60). Keegan et al37 profiled footwear worn at time of fall by participants who fractured and those who did not and found that medium-to-high heel height was associated with increased risk of fracture of the foot (OR=2.0), distal forearm (OR=1.7), proximal humerus (OR=1.5), pelvis (OR=1.5) and shaft of the tibia/fibula (OR=1.7). Tencer et al40 found a significant association between high heels and fall risk in older adults (OR=1.9). Gabell et al36 found that heel height habit was among the top 2 predisposing factors for falls in older adults even though no participant was wearing high heels at the time of falling. Moreover, past wear of high heels was associated with increased risk of multiple rather than single falls. Nagata39 found that 74% of occupational stair injuries to women under the age of 24 involved high-heeled or semi-high-heeled shoes, with women wearing these shoes being particularly prone to fall after catching the heel on the edge of the steps. Sherrington and Menz,41 however, found that only 2% of participants were wearing high heels at time of fall-related hip fracture and that no association was found between tripping or slipping and use of high heels.
The body of evidence regarding first-party injury is larger than the other outcomes in this review and is consistently positive with the exception of one study41 in which only footwear worn at the time of fall was considered and very few participants (2%) in this study were wearing high heels at the time of their fall, which would result in statistical power problems in comparing the outcome of times when high heels were or were not worn. Nagata39 usefully highlights the potential hazard of climbing stairs in high heels, while Gabell et al36 highlight that the physiological impact of wearing high heels may predispose women to a greater risk of falling even when they are not wearing high heels at the time of their fall. This finding should be interpreted in combination with evidence of stiffening and shortening of the Achilles tendon54 and radiographic evidence of alterations to the spinopelvic structure55 associated with use of high heels. Indeed, these structural adaptations may be a possible explanation for the finding of Gabell et al36 that high heels wearing habit may predispose women to falling even when not wearing high heels at the time of the fall. The two studies assessing ED presentations1838 provide insight into the clinical significance of first-party injury from high heels and especially the larger study by Moore et al38 gives insight into both the clinical and demographic spectrum of injuries incurred. The injury toll among girls under the legal age of adulthood including a large number of under 10s is striking. However, neither study classified age in a way that allows precise division of legal adults from those below the legal age of adulthood.
We have a number of suggestions for future research. First, noting that the absence of evidence is not evidence of the absence of a relationship,60 further epidemiological research is required to assess the potential association between high heels and OA as suggested by biomechanical studies but not evidenced in the current review. Second, the risk of second-party injury associated with clothing in general and high heels in particular is an area that has been under-researched and deserves further attention. Third, building on the work of Dilley et al8 and Woodward,7 it is recommended to investigate the level of awareness of health issues relating to high heels, what role this plays in footwear choice and whether certain categories of women (eg,competitive sportswomen and health professionals) are less likely to wear high heels than the general population. These studies would help determine the likelihood of a health educational intervention being effective, noting that considerable information on high heels and health is already available to the public from sources such as WebMD61 and media reports of research on high heels. Fourth, we suggest that use of high heels is taken into account in future studies of women's and musculoskeletal health to address the potential confounding effects of the use of high heels on the relationships being investigated.
This review has several notable strengths. First, it provides what is to our knowledge the first review of the relationship between high heels and health from an epidemiological perspective. Second, it situates the evidence in the context of wider public debate. Third, it offers a systematic approach to inclusion, data extraction, quality assessment and reporting in order to minimise the risk of bias. Fourth, drawing on the linguistic skills of the authors, articles in seven languages could be considered for inclusion. Fifth, this review included a range of clinically relevant outcomes in order to maximise clinical and policy relevance.
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