Recently, I was asked by a restaurant chain to provide some heel height guidelines for their servers. I was excited by this topic since I worked as a server when I was in school. This gave me an interesting perspective as a former waitress and as a podiatrist. How do you find a shoe that's work appropriate and stylish without hurting your feet?

The human foot was not designed to wear shoes, any shoes. That being said, our feet were not designed to withstand our cold climate or concrete surfaces, either. Being that this is our reality, let’s talk about how to navigate shoes for our environment.

Humans carry the majority of their weight midline as opposed to the outside of the body. Because of this, we are more likely to pronate (roll inward on the foot) than to supinate (roll to the outside of the foot). Pronation can often lead to leg fatigue, heel pain, arch strain, bunions, stiffness at the big toe joint and pain under the ball of the foot. People that supinate often have hammer toes, pain under the ball of the foot, difficulty dorsiflexing adequately at the ankle joint and shin splints.

Before getting into specifics, I would like to address quite generally the effect that heel elevation has on the biomechanics of the body. The most common misconception is that a flat shoe will be more comfortable, after all, the weight will be shared equally by the forefoot and rear foot. In fact, a flat shoe encourages pronation which will force the foot and leg muscles to work harder and fatigue faster. As well, there is a tendency to curl the toes to keep the shoe on the foot which leads to hammer toes and early fatigue of the muscles at the front of the leg. Too high a heel will cause shortening and tightening of the Achilles tendon and force the muscles at the front of the leg to work harder to counter the increased pull of these opposing muscles. As well, the pelvis will tilt forward causing the back to arch and leading to low back strain. To put some numbers to this, the pelvic tilt is 25 degrees when barefoot. In a 1” heel, it is 35 degrees, 45 degrees in a 2 inch heel and 60 degrees in a 3 “ heel. The amount that the knee has to flex in order to walk is also greatly increased by shoes greater than 2”.

The ideal heel height, assuming you are wearing a dress shoe for work would be between ½” and 2” depending on the available motion at the big toe joint and the range of motion and stability of the ankle joint. This will create some inversion of the foot, basically countering prontion and thereby decreasing leg fatigue. For the supinator, the ankle will be placed in a more comfortable position.

There are several aspects to the fit. The heel of the shoe should be centered directly under the heel of the foot and follow the natural line of the body. (Look at yourself sideways in a full length mirror). The chunkier the heel, the more stable the shoe is.

Thickness or a platform under the ball of the foot often provides some padding. For those who really love the look of a higher heel, the good news is that you can subtract the height at the front from the back, allowing you to wear what appears to be a higher heel. You may want to consider filling in the space behind (not over) the ball of the foot with a metatarsal pad. This will help prevent the foot from sliding forward and fill up an area of the shoe that is often hollowed out by the manufacturers for esthetic purposes. Be aware that a platform that runs the length of the shoe will prevent the foot from bending, which may be beneficial if you have a stiff, painful big toe joint, but will decrease your stride length causing earlier fatigue if you’re walking as opposed to just standing. The extra weight of a platform may also contribute to fatigue.

Make sure there is enough shoe to hold your foot. A stiffer and higher heel counter will secure the heel and prevent the foot from sliding forward. Ensure that there is enough room to wiggle your big toe. When wearing a heel, there is a tendency to “lip up” at the tip of the big toe. Ensuring the toe box is deep enough will decrease the risk of damage to the nail. A rounded or almond shaped at the toe is less likely to squeeze the toes. Although it is possible to wear a pointed toe comfortably, the increase risk of tripping hardly justifies the effort. A leather shoe is preferable to a synthetic as it will give over pressure areas. A leather upper can be spot stretched over pressure areas by a cobbler. Seams or decorative stitching on the upper will prevent it from stretching.

My next articles will talk about how to deal with hammer toes, bunions, corns and calluses.