• The research on heels is clearer than for most shoe questions. A large review that pulled together 18 studies linked high heels to bunions, aches and pains, and injuries — but not to arthritis.
• How high the heel is matters more than whether you wear heels at all. A review that combined 19 studies found that high and medium heels make your muscles work much harder, while low heels under 4 cm make them work only slightly to moderately harder.
• The biggest warning sign for a sprained ankle is pain while you are wearing heels. In one study of 203 women, pain in heels made a sprained ankle nearly ten times more likely — far more than heel height itself.
• Heels do not give you bunions out of nowhere. About half of the reason some people get bunions and others do not comes down to their genes. Heels seem to make a bunion worse, and make it develop faster, if you were already prone to one — they do not create one from scratch.
• This article is not telling you to stop. The researchers who found these harms said clearly that women should be free to choose — the problem is being made to wear heels, not choosing to.
• Most party-season foot trouble comes from how long you wear heels, not the shoes themselves. Four hours standing in stilettos is very different from an hour sitting down in a chunky block heel.

Between now and the new year, a lot of people will spend more time in heels than they have all year — and every January, we see the results in clinic. So here is what the research really shows, separating what we know for sure from what people repeat just because it sounds right.

The best single source is a large review. The researchers searched 644 papers in seven languages and picked out 18 studies that looked at what happens to people who wear heels.¹ They looked at four different problems — and, helpfully, did not find the same answer for all of them.

A later review, which looked at all the earlier reviews together, came to the same conclusions — with one important extra point.² Studies of how people walk and move in heels do show changes that you would expect to raise the risk of arthritis over time, even though studies of large groups of people have not yet shown it. In other words, we have not proved a link — but we have not ruled one out either.

I have written elsewhere that bunions are substantially genetic — about half of the reason some people get them comes down to the genes they inherit — and that shoes are not the reason you have one. That is still true, and it fits with this review better than it might first seem.

Three out of four studies finding a link does not prove that heels cause bunions. Most of these studies looked at people at a single point in time, so they cannot show which came first. There is also an obvious catch: people with wider feet who are prone to bunions may choose, notice and report their shoes differently. What the research best supports is that heels make a bunion worse, and probably make it develop faster, in someone who was already prone to one — not that they create one from nothing.

Toe shape and heel height are different problems

Two things often get mixed up here. A pointed toe squeezes the front of your foot from the sides — that is the part that matters for bunions and for nerve pain between the toes. Heel height tips your weight forward onto the ball of your foot. Many party shoes do both, but they are different problems — and a block heel with a wide toe solves one of them completely.

A review that combined 19 studies, involving 401 people, measured how hard muscles work during walking in different heel heights.³ Heels made muscles work much harder overall — especially the calf muscles, the muscles on the outside of the ankle, the muscles at the front of the thigh, the stomach muscles and the muscles that keep your back upright.

The most useful finding was that the higher the heel, the bigger the effect:

Calves and the Achilles

The extra work your calf muscles do also explains why many people get tight calves and a sore Achilles (the tendon at the back of the heel) after a few weeks of wearing heels. Spending long periods with your heel raised keeps the calf and Achilles short. Going back into flat shoes the next morning then asks them to stretch out suddenly.

Knees and back

Further up the body, a study that measured how people walk found that walking in high heels clearly increased the pressure between the kneecap and the thigh bone, and changed the forces acting on the knee.⁵ And a review of studies on low back pain found that 9 out of 11 linked it to wearing heels — although none could say at what heel height the problem starts.⁶

A study of 203 women who wear heels at work looked at what made a sprained ankle more likely.⁴ Heel height and thin stiletto heels both mattered — women in heels of 10 cm or more were more likely to report a sprain. But when the researchers looked at all the factors together, they found something more useful:

Pain while wearing heels was by far the biggest warning sign — bigger than the height of the heel. That is worth taking seriously, because most people treat pain in heels as something to put up with, rather than as a useful warning.

The same study found that more than three-quarters of the women who sprained an ankle had to take time off work as a result. If a sprain has not settled, see why an ankle sprain can still hurt months later.

It would be easy to end here by telling you to stop wearing heels. I am not going to, and neither did the researchers.

The team behind the most thorough review of this research also looked at why people wear heels, and found that people consistently feel they get real benefits from them.² They concluded that heels have genuine benefits and genuine health costs. Because of this, women should be free to choose — but any pressure to wear heels, whether openly stated or unspoken, should be tackled.

I think that is the right way to look at it, and it matches what I see in clinic. Almost everyone knows that stilettos are not designed for comfort. What people really want to know is how to get the balance right — and whether the pain they are getting is normal or a warning sign.

• Lower the heel before you give up heels. A heel under 4 cm gets you most of the benefit for your body.
• Choose a wider toe, not just a lower heel. A pointed toe is what matters for bunions, pain in the front of the foot and nerve pain between the toes.
• Choose a block heel over a stiletto. A wider heel is more stable, and the ankle sprain research points to stilettos in particular.
• Think about how long you wear them. Limit the hours, sit down when you can, and avoid standing for long stretches — standing for more than four hours a day raised the risk of a sprain on its own.
• Travel in flat shoes and change when you arrive. It is not glamorous, but it works very well — and more and more people do it.
• Use padding under the front of the foot. Ball-of-foot pads (metatarsal pads) or gel cushions really do reduce the pressure under the ball of the foot.
• Stretch your calves before and after a long day in heels, and do not switch straight into completely flat shoes the next morning.
• If it hurts, take them off. People with pain in heels were nearly ten times more likely to have sprained an ankle. Pain is a warning sign, not a price you have to pay.

Discomfort that goes away when you take your shoes off is one thing. But see a doctor or foot specialist if you have:

• Burning, tingling or electric-shock pain between the toes that carries on after you take your shoes off — this points to a nerve problem rather than simple pressure
• Pain under the ball of the foot that is now there in flat shoes too (metatarsalgia)
• A bunion that is changing quickly, or starting to push the second toe out of position
• A big toe that is becoming stiff rather than just sore — a different problem from a bunion
• An ankle that keeps giving way, not just one sprain
• Pain that lasts days after an evening out, rather than hours

If pain in the front of your foot, a bunion that is getting worse or an ankle that keeps giving way is limiting what you can wear, it is worth getting it properly checked rather than putting up with it for another year.

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