Sole Mates

My shoes are special shoes for discerning feet. -
Manolo Blahnik

All of my patients, and friends, and aquaintances know this about me: I am very concerned about posture. It is wierdly satisfying to walk into a business meeting and have the whole room sit up straight in their chairs. It is a little disconcerting when my patients walk in bare-foot, to avoid the lecture about high heeled shoes.

A former patient sent me an abstract concerning ankle position and pelvic floor muscle activity. The authors are Charles Vega, MD and Laurie Barclay, MD. As I only have the abstract, I'm not sure about the details of the study, but apparently the information was intended for continuing education credits. The gist of the article is: When your feet are in dorsiflexion (toes pointing up), there is more activity in your pelvic floor muscles (pfm), and it is easier to build a strong contraction. When your feet are in plantar flexion (heels up, toes down), there is less activity and it is harder to build an effective muscle contraction.

Before we jumped to the conclusion that if you have tight pelvic floor muscles you should wear high heels, lets look at the details. The study was conducted on women that had stress urinary incontinence. Although not specifically mentioned, we can assume that many of these women had weak pfm. The women were tested in neutral standing, 15 degrees of dorsiflexion and 15 degrees of plantar flexion. They stood in these positions for 5 minutes prior to testing. Resting muscle activity and maximal contraction were recorded. The results show that the plantar flexion position (toes down) had less muscle activity at rest than neutral and dorsiflexion. A stronger contraction is possible with the toes up.

So what does this mean for you? The only specific conclusion drawn by the authors was that pfm exercise in conjunction with raising your toes will be helpful in training women with stress urinary incontinence. We get into trouble in medicine when we take information from a study and apply it to a different population without really researching the details. We have no idea what ankle placement will do with a pathologically tight pelvic floor. Even if 15 degrees of plantarflexion will relax the pelvic floor, realize that 15 degrees is not much, perhaps only a 3/4" - 1" heel. This will come as a shock to some of my patients, but I don't have too much of a problem with 1" heels, as long as it doesn't go any higher and they spend some or most of their day in good, supportive shoes. Also, this study only measures the pfm activity, and does not take into consideration the rest of the body. We know that pelvic pain problems can be exacerbated by mechanical imbalances in the spine and pelvis, and wearing heels all day can be very hard on the back, neck and jaw.

I'm still not endorsing high-heels for pelvic pain patients, but picking up your toes when you cough or sneeze (don't fall over) will apparently help to prevent leakage.