high - heeled shoes ( hhss ) are defined as shoes in which the heel is higher than the 
 forepart .
hhss often also include a narrow toe box , rigid heel cap , and curved plantar 
 region , all of which interfere with natural foot motion .
hhss have been worn for several 
 centuries1 , and despite numerous 
 cautions against their use , they remain extremely popular .
surveys suggest that 37% and 69% 
 of women wear them in their daily lives , representing a huge proportion of the female 
 population2 .
the use of hhss cause abnormal postural alignment , particularly in the lower limbs and 
 spine3 .
thus , increased forward head 
 posture , lumbar hyperlordosis , pelvic anteversion , and valgus knees .
standing in hhss causes 
 immediate and temporary postural changes because of forward shifting of the center of 
 gravity3 .
when hhss are removed , the 
 body goes back to its original alignment . however , previous studies4 indicated that the permanence of postural changes with 
 excessive use of hhss .
additionally , wearing hhss has been associated with an increased potential for slips and 
 falls because the consequent changes in local sensation around the ankle may affect posture 
 balance in women5 . if the heel height is 
 > 5  cm , women tire easily because it is more difficult for the feet to balance the body 
 weight5 .
they attempt to 
 provide a more normal physiologic standing posture and static balance than general hhss by 
 making use of tunnel technology with excellent shock absorption and a rearward decrease in 
 the wedge angle .
the purpose of this study was to investigate the effects of revised hhss on 
 the foot pressure ratio and static balance during standing .
the subjects were 15 young women ( 21.7  2.1  years ; 161.2  5.8  cm ; 50.4  5.6  kg ) in one 
 of two conditions : ( 1 ) wearing general hhss with a heel height 7  cm , or ( 2 ) wearing revised 
 hhss with a heel height 7  cm .
exclusion criteria were past or present neurological or musculoskeletal diseases , 
 contractures of the lower limbs , and significant weakness of the quadriceps muscles that 
 would preclude full knee extension while sitting .
in addition , pregnant women or women with 
 any psychological problems were excluded . in order to get familiar with the test shoes
, 
 subjects were allowed to wear several different sizes , and were allowed to familiarize 
 themselves with the walk around .
foot pressure ratio and static balance were measured during standing tasks using a 
 spacebalance 3d system ( cybermedic corp . ,
the spacebalance 3d 
 system was equipped with 2 wireless force plates ( foot placement : 20  cm from heel to heel 
 and 24  cm from toe to toe ) that recorded the weight distribution of 4 zones ( front , back , 
 left , and right ) , and a sensor located in the front measured plate inclination . during 
 measurements
the foot 
 pressure ratio was calculated as the ratio between the front and back pressures and , 
 expressed as a percentage ( % ) .
static balance was evaluated under 3 conditions ( eyes open , 
 eyes closed , screen blocked ) , and the balance posture ratio ( bpr ) score was calculated by 
 multiplying by a weight ( a= 100% , b= 80% , c= 60% , d= 40% , and e=20% ) to zone ( a  e ) 
 ratio .
data analysis was performed using spss version 21.0 ( ibm corporation , armonk , ny , usa ) .
the 
 kolmogorov - smirnov test was used to assess the normality assumption . after verifying that 
 the data were normally distributed
the 
 independent t - test was used to compare the data between the revised hhss and general hhss . 

the forefoot pressure ratio was 51.5% for the revised hhss and 62.0% for the general hhss , 
 and the differences between the hhs conditions were significant .
the rearfoot pressure ratio 
 was 48.5% for the revised hhss and 38.0% for the general hhss , and the differences between 
 the hhs conditions were significant .
the static balance score was higher for the revised 
 hhss than for the general hhss under all 3 conditions .
however , the differences between the 
 two types of hhs were not statistically significant ( table 1table 1.comparison between the general and revised high heeled shoes ( hhss)variablerevised hhssgeneral hhssforefoot ( % ) 51.5  4.962.0  7.3*rearfoot ( % ) 48.5  4.438.0  5.8*eyes open ( score)90.7  5.288.7  4.9eyes closed ( score)88.2  6.885.1  6.2screen blocked ( score)88.2  7.187.0  6.0*p<0.05 ) .
standing while wearing hhss causes forward weight shifting due to the change in the plantar 
 pressure and in the location of the center of gravity ( cg)3 . wearing hhss first provoke elevation of the calcaneus bone6 . changing the forward displacement of the 
 cg , resulting in postural imbalance and promoting adaptive postural adjustments for balance 
 recovery3 , 6
this occurs because of the adaptability of the postural system , 
 which meets the demands of the excessive or attenuated postual muscle activities against 
 gravity .
so that , either by increasing the heel height , or decreasing the base of support , 
 results in joint pain , muscle shortening , and forefoot deformities3 .
revised hhss were developed to address the weaknesses of general hhss , and the purpose of 
 this study was to investigate the effects of revised hhss on the foot pressure ratio and 
 static balance during standing .
when wearing general hhss , the pronounced misalignment of the ankle in plantar flexion and 
 increased plantar pressure in the forefoot area promote overload of the forefoot7 .
schwartz et al . demonstrated that at a 5-cm 
 heel height , pressure under the forefoot increases and heel pressure decreases8 .
consequently , the ankle joint axis moves 
 anteriorly , and the line of gravity moves posteriorly toward the ankle joint9 , 10 . 

moreover , van der leeden et al . established a relationship between joint damage and 
 increased forefoot pressure11 .
in the 
 same way , a reduction in the weight bearing area in hhss can result in pain12 .
furthermore , the thinner the shoe heels , 
 the greater the instability of the ankle , the overall imbalance , and the postural 
 impairment3 .
. however , habitual wearing of 
 hhss seems to lead to greater strength through the range of ankle joint plantar flexion , 
 compensating for the loss of control13,14,15 .
our study demonstrated that revised hhss produce significantly higher rearfoot pressure and 
 lower forefoot pressure than general hhss .
additionally , revised hhss have a greater 
 positive effect than general hhss on static balance .
revised hhss seem to normalize 
 physiologic standing posture and static balance by making use of tunnel technology with 
 excellent shock absorption and a rearward decrease in the wedge angle . in conclusion , this 
 study showed that in comparison with general hhss , revised hhss produce higher pressure on 
 the rearfoot , lower pressure on the forefoot , and improved balance control .
the only limitation of this study is that the alteration during standing for the revised 
 hhss was not based on a sufficient variety of methods .
further research should be conducted 
 to determine the effects of the use of revised hhss on posture with a larger number of 
 subjects and a variety of methods .
 [ purpose ] the purpose of this study was to investigate the effects of revised high - heeled 
 shoes on the foot pressure ratio and static balance during standing . 
 [ subjects and 
 methods ] a single - subject design was used , 15 healthy women wearing revised high - heeled 
 shoes and general high - heeled shoes in a random order . 
 the foot pressure ratio and static 
 balance scores during standing were measured using a spacebalance 3d system . 
 [ results ] 
 forefoot and rearfoot pressures were significantly different between the 2 types of 
 high - heeled shoes . 
 under the 3 conditions tested , the static balance score was higher for 
 the revised high - heeled shoes than for the general high - heeled shoes , but this difference 
 was not statistically significant . 
 [ conclusion ] revised high - heeled shoes are preferable 
 to general high - heeled shoes , as they result in normalization of normalized foot pressure 
 and a positive effect on static balance . 