Letter to the Editor concerning "High-heeled-related alterations in the static sagittal profile of the spino-pelvic structure in young women" by Min Dai et al. [Eur Spine J (2015); DOI 10.1007/s00586-015-3857-6

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I read with some interest the recent article in European Spine Journal by Dai et al. [1], High-heeled-related alterations in the static sagittal profile of the spino-pelvic structure in young women. I think there are interesting aspects of the study but that it also has some problems. I wish to comment on a couple of points involving the effect of high-heeled shoes on lumbar lordosis. When Dai et al. make the statement that ‘‘Some studies have shown that high heels increase lumbar lordosis...’’ they cited Cowley’s 2009 review article [2]. Note that Cowley’s article was not a ‘‘study’’, but rather a review of the literature. In fact, not only did Cowley NOT conclude that high-heeled shoes increase lordosis, she cited studies by de Lateur and Snow showing no significant difference in lordosis for different heel heights [3, 4], and a study by Franklin [5] that found decreased lordosis. Dai et al. themselves incorrectly cite Snow [4] as having found increased lordosis. The authors did not mention several other studies of highheeled shoes and lordosis and, therefore, failed to show they have a familiarity with the previous research on the topic—something which would not have been a difficult task, as they only needed to read about a dozen articles. I believe European Spine Journal’s peer reviewers did not do an adequate job of screening the references. My main complaint, though, is their conclusion that their findings of increased lumbar lordosis ‘‘...may help explain why some women complain that wearing highheeled shoes causes them to experience low back pain.’’ No, their findings do not do that at all. Dai et al. studied teenagers with little or no experience in wearing highheeled shoes, beyond the 1-h adaptation in the study. Female patients with low back pain, however, are typically adult women in the range of, say, 30–50 years, who may wear high-heeled shoes often, for many hours per day, and for many years. Dai et al. may have missed the part of Cowley’s article that cited Opila-Correia [6], who found increased spinal lumbar lordosis in inexperienced wearers of high heels, an effect ‘‘not evident in experienced wearers, indicating the potential habituation in experienced wearers of high heels’’ [2], and perhaps overlooked the implications of that statement for their own study. Their future research does not simply need a larger sample size— it needs a sample more representative of a population with back pain. The major problem is that most people will only read the conclusion. Internet media outlets will perhaps pick it up and reinforce the urban myth of high-heeled shoes increasing lumbar lordosis. If so, Dai et al. have undone decades of research that mostly, for the general population, contradicts their findings. Their study might have been sound from a pure science approach but has little external validity. It is my opinion that the above points should be revised for a final publication version of the article.