We frequently receive great questions from readers that show a lot of insight, and we will do our best to share the questions and our response. The following is a comment we just received this week regarding the influence of shoe heel height on spondy-related pain.
Here is Tom's question (not edited in any way):
Hi again. I have one more question for you. This is regarding shoe heel height and and its effect if any on spondylolisthesis.
I have read that people with spondylolisthesis (I have grade 1, not always symptomatic) should avoid high heels and perhaps that they should wear low heeled shoes. The reason given is because it is said that high heels cause the lower back to become more lordotic, arching in, putting pressure on the low back and maybe adding shear force on the lower vertabrae.
I've also read that really "high heels" are bad for everyone (usually women in this case), because they deform the foot and also can lead to back strain due to increased lumbar lordosis.
I've also read to the contrary that high heels do not cause lumbar lordosis (they do the opposite) nor do they cause pain:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3206568/
I've also read of a case study that showed a woman had pain from her spondy when she wore low heeled shoes.
So I am a little confused. Being a guy, I'm not going to wear very high heeled shoes. I usually wear running shoes for walking. But they do come in different heel heights... or more accurately, different heel toe differentials. Many running shoes for example use a 12mm-14mm differential (difference between height of heel and forefoot). Lately though, with the minimalist/barefoot running trend, shoes have been dropping their heel heights and advertising their heel to toe drops as a selling point. It is said that a lower heel/heel toe drop makes it easier to land on the mid foot when running which is thought by some to be better than heel striking, which supposedly higher heels encourage.
Anyway, do you think heel height (heel toe differential), in a moderate range of say 14mm to totally flat, has any impact on spondylolisthesis one way or the other?
I'm asking because I have generally have found that low heeled shoes do seem to cause a little back aching (though barefoot feels fine). I have also found the same with shoes that have higher heels than I am used to.
Just wondering if it is just an issue of getting used to a shoe height or if there is a spondy interaction and if there is any real evidence for the suggestion to wear low heeled shoes for spondy.
Thanks again for your time and patience!
Tom
Here is our response:
That's a great question, Tom, and I'll have to agree that there is no concrete answer. In my experience, and based on what other evidence I have read, there is no guarantee that the height of the shoe's heel will create pain.
The structure and design of the human body leads to an ideal posture, which of course varies a bit from person to person. There are different ways in which our nervous system makes use of sensory information such as the length of muscles and positions of joints. And this information is used to help us adjust our posture or move fluidly so that we can interact with the world around us. Our bodies are constantly making adjustments based on this information.
So your nervous system will have to make adjustments in your posture or your movement patterns if you drastically change your joint position away from this "ideal" by wearing shoes that raise your heels higher than you are used to (or drop them lower, like with the emergence of "barefoot" shoes).
When you wear shoes that raise your heels above your toes, your body's center of mass is slightly shifted upward. Your nervous system adjusts to this by making your calf muscles more active in order to keep you on your feet. Stay in those shoes long enough and you're going to have tight calf muscles - overworked from trying to keep you upright.
Another problem of spending a lot of time in shoes that raise your heel level is that your normal ankle joint mobility is restricted. This is important because in many cases of normal activities, your joints generally alternate between preferring a role of either stability or mobility. Starting with the feet and moving up....feet (stability), ankles (mobility), knees (stability), hips (mobility), low back (stability), upper back (mobility), shoulder blades (stability), and shoulders (mobility). This is the Joint-by-Joint Approach popularized by physical therapist Gray Cook and strength coach Mike Boyle.
So shoes with a heel raise effectively reduce the potential mobility at the ankle. This change has to be accounted for in other joints, especially above and below the ankle. So the foot or the knee give up some of their inherent stability in order to gain a little more mobility. This may set the stage for even more changes up the kinetic chain, which may have a big influence on your spondy.
Makes a good case for why ladies shouldn't wear high heels, right? And it might even scare you from wearing running shoes since traditional running shoes raise the heel "significantly" when compared to standing barefoot.
So "barefoot" shoes must be the ticket! But of course, that would be too easy. Structural changes to the foot may mean a quick change to barefoot/minimalist shoes is met by new aches and pains that stress the body's tissues. Barefoot or minimalist shoes require the foot to provide adequate stability and the ankle to provide adequate mobility. If you have calf muscles that are tight from overcompensating from day after day in running shoes, then an abrupt switch to barefoot/minimalist shoes will overly stress the calves by requiring flexibility that the muscle isn't ready to provide. Again, something else will have to compensate and now you've got potential problems elsewhere or at your low back.
However, if your muscles and connective tissues have adequate mobility, your foot structure is adequate, and your nervous system can make the needed adjustments to provide stability, then there won't be much of an issue transitioning to barefoot shoes.
The theory that the type of shoe creates increased lordosis at the low back, or any other postural change, is really just a function of whatever compensatory mechanisms are already present. The shoe is just exaggerating a problem that already exists.
So there you have it. There is no simple answer to what type of shoe or level of heel raise is best for everyone. If someone has restricted mobility and altered movement patterns, then the main focus should be on correcting the restrictions and improving the movement - no matter what type of shoe they wear.
In your particular case, Tom, since you say both low-heeled and higher-heeled shoes cause discomfort, then one possibility is that you may have restrictions in flexibility or joint mobility that are being exposed by either type of shoe you wear, so you would need to address those movement issues.
Another possibility, since you say you feel fine when actually barefoot, is that your shoes are robbing your feet of something feet love to do - provide feedback. Your feet, along with the fingertips, are densely packed with nerve endings. When you are barefoot your body is getting all kinds of information that the body uses to maintain posture or provide movement. Again, your shoes may be robbing you of valuable sensory information.
Thanks for the questions, Tom, and best wishes while keeping yourself feeling great!
Here is Tom's question (not edited in any way):
Hi again. I have one more question for you. This is regarding shoe heel height and and its effect if any on spondylolisthesis.
I have read that people with spondylolisthesis (I have grade 1, not always symptomatic) should avoid high heels and perhaps that they should wear low heeled shoes. The reason given is because it is said that high heels cause the lower back to become more lordotic, arching in, putting pressure on the low back and maybe adding shear force on the lower vertabrae.
I've also read that really "high heels" are bad for everyone (usually women in this case), because they deform the foot and also can lead to back strain due to increased lumbar lordosis.
I've also read to the contrary that high heels do not cause lumbar lordosis (they do the opposite) nor do they cause pain:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3206568/
I've also read of a case study that showed a woman had pain from her spondy when she wore low heeled shoes.
So I am a little confused. Being a guy, I'm not going to wear very high heeled shoes. I usually wear running shoes for walking. But they do come in different heel heights... or more accurately, different heel toe differentials. Many running shoes for example use a 12mm-14mm differential (difference between height of heel and forefoot). Lately though, with the minimalist/barefoot running trend, shoes have been dropping their heel heights and advertising their heel to toe drops as a selling point. It is said that a lower heel/heel toe drop makes it easier to land on the mid foot when running which is thought by some to be better than heel striking, which supposedly higher heels encourage.
Anyway, do you think heel height (heel toe differential), in a moderate range of say 14mm to totally flat, has any impact on spondylolisthesis one way or the other?
I'm asking because I have generally have found that low heeled shoes do seem to cause a little back aching (though barefoot feels fine). I have also found the same with shoes that have higher heels than I am used to.
Just wondering if it is just an issue of getting used to a shoe height or if there is a spondy interaction and if there is any real evidence for the suggestion to wear low heeled shoes for spondy.
Thanks again for your time and patience!
Tom
Here is our response:
That's a great question, Tom, and I'll have to agree that there is no concrete answer. In my experience, and based on what other evidence I have read, there is no guarantee that the height of the shoe's heel will create pain.
The structure and design of the human body leads to an ideal posture, which of course varies a bit from person to person. There are different ways in which our nervous system makes use of sensory information such as the length of muscles and positions of joints. And this information is used to help us adjust our posture or move fluidly so that we can interact with the world around us. Our bodies are constantly making adjustments based on this information.
So your nervous system will have to make adjustments in your posture or your movement patterns if you drastically change your joint position away from this "ideal" by wearing shoes that raise your heels higher than you are used to (or drop them lower, like with the emergence of "barefoot" shoes).
When you wear shoes that raise your heels above your toes, your body's center of mass is slightly shifted upward. Your nervous system adjusts to this by making your calf muscles more active in order to keep you on your feet. Stay in those shoes long enough and you're going to have tight calf muscles - overworked from trying to keep you upright.
Another problem of spending a lot of time in shoes that raise your heel level is that your normal ankle joint mobility is restricted. This is important because in many cases of normal activities, your joints generally alternate between preferring a role of either stability or mobility. Starting with the feet and moving up....feet (stability), ankles (mobility), knees (stability), hips (mobility), low back (stability), upper back (mobility), shoulder blades (stability), and shoulders (mobility). This is the Joint-by-Joint Approach popularized by physical therapist Gray Cook and strength coach Mike Boyle.
So shoes with a heel raise effectively reduce the potential mobility at the ankle. This change has to be accounted for in other joints, especially above and below the ankle. So the foot or the knee give up some of their inherent stability in order to gain a little more mobility. This may set the stage for even more changes up the kinetic chain, which may have a big influence on your spondy.
Makes a good case for why ladies shouldn't wear high heels, right? And it might even scare you from wearing running shoes since traditional running shoes raise the heel "significantly" when compared to standing barefoot.
So "barefoot" shoes must be the ticket! But of course, that would be too easy. Structural changes to the foot may mean a quick change to barefoot/minimalist shoes is met by new aches and pains that stress the body's tissues. Barefoot or minimalist shoes require the foot to provide adequate stability and the ankle to provide adequate mobility. If you have calf muscles that are tight from overcompensating from day after day in running shoes, then an abrupt switch to barefoot/minimalist shoes will overly stress the calves by requiring flexibility that the muscle isn't ready to provide. Again, something else will have to compensate and now you've got potential problems elsewhere or at your low back.
However, if your muscles and connective tissues have adequate mobility, your foot structure is adequate, and your nervous system can make the needed adjustments to provide stability, then there won't be much of an issue transitioning to barefoot shoes.
The theory that the type of shoe creates increased lordosis at the low back, or any other postural change, is really just a function of whatever compensatory mechanisms are already present. The shoe is just exaggerating a problem that already exists.
So there you have it. There is no simple answer to what type of shoe or level of heel raise is best for everyone. If someone has restricted mobility and altered movement patterns, then the main focus should be on correcting the restrictions and improving the movement - no matter what type of shoe they wear.
In your particular case, Tom, since you say both low-heeled and higher-heeled shoes cause discomfort, then one possibility is that you may have restrictions in flexibility or joint mobility that are being exposed by either type of shoe you wear, so you would need to address those movement issues.
Another possibility, since you say you feel fine when actually barefoot, is that your shoes are robbing your feet of something feet love to do - provide feedback. Your feet, along with the fingertips, are densely packed with nerve endings. When you are barefoot your body is getting all kinds of information that the body uses to maintain posture or provide movement. Again, your shoes may be robbing you of valuable sensory information.
Thanks for the questions, Tom, and best wishes while keeping yourself feeling great!
