High Heels, Pelvic Floor, and Bad Science

I have a twitter account and I’m not afraid to use it.

Last week I read this:

“@fitnessleak: study shows 3″ high heels worn by women created stronger pelvic muscles lead 2 better sex @AlignedandWell what do u think?

For those of your who don’t know twitter-speak, this means “Hey, Katy, what do you think of what Fitnessleak wrote — that a study shows that 3” heels worn by women created stronger pelvic muscles that lead to better sex.?

What do I think? What do I think? I think I want to put a hot poker in my eye.

This is not the first time someone has asked me my opinion about this article. I thought I’d answer it here, so you can all enjoy my answer 🙂

Once upon a time there was a high-heeled wearing urologist that stumbled across an article linking high heel use to schizophrenia (you should read the article, it is fascinating and just one more reason that I never wear anything with a positive heel!). This caused her great alarm as she loved her heels, even saying “although they are sometimes uncomfortable, I continue to wear them in an effort to appear more slender and taller.” Because she could not refute the article, she decided to prove a healthy aspect of heels.

She and her team created a study looking at changes in ankle positions that change pelvic tilt (that’s tucking or untucking your pelvis from a neutral position) and changes in pelvic floor activity. She measured this in 15 women. It is important to note that she did not have any of her subjects in shoes. That’s right. No shoes were worn by the people in the study. They just stood on wedges of different angles.

Here’s where it gets a little nerdy. She based her study on a previous study looking at the same thing: how does ankle position affect pelvic position and how does pelvic position affect pelvic floor contraction. I’ll call this the Chen study, after the lead researcher.  The Chen study found that each ankle/pelvic angle brought about a different PF activity. They measured both resting and maximal (trying to squeeze it the tightest) force production.

The results? The greatest PF change came with DORSIflexion, which is the opposite of being on your toes.

Dorsiflexion looks like this:

All measured dorsiflexion angles had higher PF activity than plantarflexion.

Plantarflexion looks like this:

Dr. Highheel’s study also measured both resting and maximal contractions and here are her results:

The left column shows ankle position. HS is flat, the P stands for plantarflex (what happens in a high heel) and D stands for dorsiflex (what happens in a negative-heeled shoe).

What do you see, my little research students?

1. The greatest resting activity in the PF is, like the Chen study, higher with heels down, not heels up.

2. The maximal contraction (squeezing it hard) comes from 5° of plantar flexion (less than 1/2” of heel) not those ankle positions simulating 2 or 3″ heels.

The conclusion of the study: Ten degrees of dorsiflexion (opposite of heels, remember?) might be just as effective as the 15° reported by Chen, but more comfortable. Low heels – not high heels.

How does one walk around in dorsiflexion? I don’t know. The researchers don’t know. It’s just a study, not a practical guide on how to use the information! And remember, they aren’t measuring walking – just standing on an angled board for a ten seconds in each position.

So how did we go from studies by Dr. Highheel and Dr. Chen, showing that dorsiflexion in the ankle gives greater resting PF readings than plantar flexion, to the headline

3” heels increase pelvic floor strength and better ooooh la la?

This is how: Dr. Highheel writes a letter to the editor to the Journal of European Urology called: Women Pay Attention to Shoe Heels: Besides Causing Schizophrenia They Might Affect Your Pelvic Floor Muscle Activity!!

(Catchy title, right?)

In this letter she says that she has done research (the research we just looked at) and that despite being linked to schizophrenia, heels might be beneficial as noted by her data. She fails to mention that dorsiflexion has been noted to have greater impact in the two conducted studies. Fails to mention that of the positive ankle positions measured, the 5-degree (the lowest) measurement of heel was “the best.”

Boo. Bad scientist. Wanting heels to be healthy (as she stated she does) skewed how she presented the material to the public. That’s a huge (HUGE!) no-no.

Of course, the media picked up on her letter to the editor and didn’t follow up with reading the research portion.

To clarify:

No shoes were used in the study. High heels (or any heels) were never measured.

Negative ankle position measured greater PF activity than positive ankle positions, not the other way around.

And, I have a bigger issue with both the Chen and the Cerruto (Dr. Highheel) studies.

How is pelvic floor contraction measured? With EMG (electromyography). An electrode picks up on the quantity of electricity flowing through an muscle and converts it to forces the muscle generated. Ideally, EMG is measured by an electrode placed into the measured muscle with a tiny needle. But not many people want a needle jammed in their pelvic floor, myself included. So researchers (and therapists) use a patch that reads electricity around the area of a muscle, through the skin.

The problem with this method is that the patch picks up every other muscle contraction in the area as well. It’s called cross-talk. And what is the nice neighbor of the PF? The lower glutes. These are the muscles you use when you’ve had 5 cups of coffee, 3 bran muffins and are sitting in traffic. They are also the muscles that you use to tuck the pelvis under. Go ahead and try it. Pretend your bowels are going to explode and you’ll feel those low low glutes squeeze your cheeks together.

Any change in ankle position, up or down, causes the pelvis to tilt from neutral, which causes the low glutes to fire. This means your PF data is automatically tainted (hee hee) with glute cross-talk. Dear researchers: You’re not even measuring what you think you are. You’re not isolating the variable!

Muscle geometry and biomechanical science demonstrates that neutral pelvis will give you the optimal pelvic strength (not too much tension and not too little) every time. Any heel, high or low causes your pelvis to tilt from neutral. I’m not a fan of walking around with my toes higher than my heels, or my heels higher than my toes. I like to be more grounded than that. Think flats or minimal footwear. But if you love LOVE shoes, go with Earth Kalso bottom. The negative is at least a little better than the positive.

And, take note on what you read. The story – High Heels Increase Pelvic Floor Strength was reported in just about every prominent health magazine, newspaper, and television network. No one bothered to check the research.

When I moved about 3 weeks ago I finally chucked my last pair of heeled shoes. Note the cobwebs…

Schizophrenia? Really? What more do you need to hear? I commented on another doctor’s poor advice in last week’s LA Times (Posh Spice, her bad back, and her high heels: http://www.latimes.com/health/boostershots/la-heb-victoria-beckham-slipped-disc-20110823,0,4494319.story. And I do a whole lot more high-heel/bad advice commenting in my new book coming out later this year, Every Woman’s Guide to Foot Pain: The New Science of Healthy Feet!

C.H. Chen, M.H. Huang, T.W. Chen, et al.. Relationship between ankle position and pelvic floor muscle activity in female stress urinary incontinence. Urology 66 (2005) (288 – 292)

M.A. Cerruto, E. Vedovi, S. Dalla Riva, et al.. The effect of ankle inclination in upright position on the electromyographic activity of pelvic floor muscles in women with stress urinary incontinence. Eur Urol Suppl 6 (2007) (102)

Flensmark. Is there an association between the use of heeled footwear and schizophrenia?. Med Hypotheses 63 (2004) (740 – 747)

Women Pay Attention to Shoe Heels: Besides Causing Schizophrenia They Might Affect Your Pelvic Floor Muscle Activity!! Maria Angela Cerruto, Ermes Vedovi, William Mantovani. Accepted 15 January 2008, Published online 24 January 2008, pages 1094 – 1095

Surface EMG crosstalk evaluated from experimental recordings and simulated signals. Reflections on crosstalk interpretation, quantification and reduction. Farina, D. Merletti, R. Indino, B. Graven-Nielsen, T. Dipartimento di Elettronica, Politecnico di Torino, Corso Duca degli Abruzzi 24, Torino, 10129, Italy.

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24 thoughts on “High Heels, Pelvic Floor, and Bad Science

  1. Best line in a blog post ever: “The lower glutes. These are the muscles you use when you’ve had 5 cups of coffee, 3 bran muffins and are sitting in traffic.”

    Love how you make me laugh my head off and teach me a little something at the same time!

  2. You go girl. I LOVED the LA times response, it reminded me of a WWF smackdown, targeted and right on the money. Doctors keeping up with the literature? Clearly, not frequently enough.

  3. Anette, I too am laughing my gluteus off. Katy, you seriously have a way of sticking your heel right into the think of it. I am RIGHT with you Katy, and ready to battle any researcher or magazine editor teetering in high heels to keep their taints taut!

  4. Ok, I am not a fan of high heels, but I dont understand the correlation between high heels and schizophrenia. Do you have the study on this? Also, I love your work…but I don’t see why the pelvis has to tuck when in heels. I dont wear them often, but if i do i don’t notice it happening and I feel pretty aware of my biomechanics. -inquisitive learner

    1. I put the references on the bottom, you can probably search and purchase the article if you’re interested. It’s not a “cause” as much as a correlation. In regards to the tuck, if you change your feet from level, the entire body tips forward right? If you put three inches under one side of a bookcase, the entire thing pitches forward. To level out, you have to go the same distance in the opposite direction. The pelvis is the largest hinge so it tucks to keep your torso vertical. You might have good poetical awareness, but what most are missing is the knowledge of what neutral pelvis is. Most people are tucked all of the time, so there isn’t much change with Or without shoes. You may also be someone who bends the knee and arches the back a little instead of adjusting solely the pelvis. There is all of the info on the no more kegels webinar if your interested in really knowing the mechanics and how to measure your body objectively.

  5. Thanks for a great response to my tweet Katy! Outrageous how research is so often flawed and mis-represented. I do notice the change in my alignment when I wear heels but must admit I do sometime still wear them (when not teaching Pilates or chasing round after my baby!).

  6. I know that flats are best if you’re going to be wearing shoes (and I’m happy about this because ALL of my shoes are flats!), but what about people like myself with really, really high arches? Most flats don’t come with arch support and I can see that my feet tip in because of it. Most of the insoles you can buy tend to include heel cushions, too! I don’t need to elevate my heel, just support my arch, right? Any advice?

    1. Perhaps I should have read your previous post FIRST and avoided talk about the arches in my feet, eh? My real question should be how do I get my feet to stop tipping in and WHY do they do that in the first place (or rather, what am I doing to make them do that in the first place)?

      1. High arches are the same issue as flat ones… Only different 🙂 it still is an indication that your muscles are too tight and weak. Strengthening your hip rotators and increasing the length of your lower leg and inner-foot muscles is the solution!

  7. I would not trust pelvic floor advice from Fitness “Leak,” if you know what I mean. Also, I had to laugh that when I received your email about this new blog post in my Gmail account, it triggered a Gmail ad for a “Manolo Blahnik shoe sale.” Your shoe pic reminds me that I have one pair of high-heeled shoes (Dansko sandals) that I wore when I got married 6 years ago. They are probably now valuable dust-bunny habitat.

  8. This is great. But I am still extremely confused about what is the RIGHT posture. Can you please post a link? I have searched but am still confused. sorry…

  9. As a former cruising sailor I must take exception to your webinar “No More Keels” that you mentioned in your response to Celeste. Difficult and uncomfortable going to windward without a keel, and lots of drift :o)

    Excellent post, Katy. It is most instructive to see and be around a scientist being scientific. Logic is one of the many wonderful aspects of humanity – when it isn’t being tortured as it is in this “study” and the L.A. Times article.

  10. Between this and all the low-fat,/high carb/vegan nonsense being reported in the media, I’m really thinking of adopting the position of doing the *exact* opposite of whatever a “study” in the media reports.

    In the last few months, I’ve started a Paleo diet and I wear minimalist footwear. It feels great to align my body with its natural proclivities!

  11. Hi Katy,

    I am trying to find a professional looking shoe that works for my body’s alignment also. Any opinions on shoes other than Earth….ie Wolky, Dansko etc?



    1. There are Earth that are perfectly professional, unless by professional you mean pointy toe, heel etc. 🙂 I know hundreds of people that wear Earth – the couture line, for office and corporate time. If you don’t like the look of the earth or other shoe-less shoe lines, then find a great all-leather flat. There are some high-end ones out there that are very pliable. Make sure there is no heel and plenty of room for your toes to move away from each other, even if it means going a 1/2 size larger. Just as long as you don’t have to grip your toes to keep them on!

  12. Your article makes me laugh and cry. You are very funny, hence the laugh, but I love my heels, hence the cry. Actually as a mother of nine, I rarely have an occasion to wear heels, but since I am 5’3 I love it when I can. I am very interested in the correlation between anything and the pelvic floor muscles (again a mother of nine who wants to continue being active for a long time.) Thanks for your always thorough information!

  13. Sadly the comments section on that Times article appears to be gone. Too bad, I was curious what you had to say about it.

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