Introduction Most women consider high-heeled shoes (HHS) as a fashion symbol. 1 The use of this specific footwear is deemed as characteristic of beauty, self-assurance and elegance. 2 It has been seen that 1 in 10 women wear it for at least three days a week and a recent survey found that one-third of them had permanent problems. 3 Many working women select footwear based on aesthetic appearance which influences the footwear design, however comfort and practicality are not necessarily considered as high a priority, thus adverse pathologies become increasingly apparent during prolonged wear. 4 Therefore, it is important to investigate and understand the effects that shoes of high heel heights have on the musculoskeletal system. For more than 50 years, concerns regarding the potential impact of HHS on women's health have been expressed in medical circles. Qualitatively consistent alterations to the neuromechanics of walking (gait) and effect on the kinematics and kinetics of bodily structures from the toes to the spine have been seen because of using HHS. 5 The frequent and prolonged use of HHS has a direct impact on the spine. Excessive spinal extensor muscles activation, which contributes to the compression of the spine, might be caused by shock and ground reaction forces which leads to excessive axial pressure onto the intervertebral discs. 6 Thus, wearing HHS for a prolonged time period can result in an increase in paraspinal musculature activation of lumbar and cervical spine, causing long term overload and fatigue in trunk and neck muscles. 6 Clinically, muscle overuse could be exacerbated by increased lumbar erector spinae muscle activity associated with wearing high heeled shoes and may lead to low back problems. 7,8 High heeled shoes users exhibit significantly lower maximum and minimal lumbar and thoracic curvature angles as compared to the barefoot condition. Therefore, low back pain might be associated with other factors caused by high heels. 9 Furthermore, at pre-swing and swing phases of gait, there is a 23% increase in hip flexor work in response to a higher hip extension moment in high-heeled gait, thereby disturbing the normal musculoskeletal action at hip. 10 HHS also contributes to the musculoskeletal changes around knee joint. The higher knee extensor moments and knee flexion angles induced can cause an increased Vol. 70, No. 12-A, December 2020 2199 RESEARCH ARTICLE Association of musculoskeletal discomfort with the use of high heeled shoes in females Wardah Hussain Malick, Hifsa Khalid, Zoya Mehmood, Hamid Hussain Abstract Objective: To determine the association of musculoskeletal discomfort with the high heeled shoes related variables in females who use such footwear frequently. Methods: A cross sectional study was conducted on 174 female residents of Islamabad and Rawalpindi, for a time period stretching from July 1, 2018 to December 31, 2018. The participants aged between 18 and 55 years appeared as the frequent users of high heeled shoes. The Nordic Musculoskeletal Questionnaire (NMQ) and Numeric Pain Rating Scale (NPRS) were used as outcome measures to assess the musculoskeletal discomfort and a self-structured questionnaire was used to obtain information related to the high heeled shoes e.g. duration and frequency of high heeled shoe use. Data was analysed by using SPSS version 21. Results: The data analysis showed a positive association of shoulders' discomfort with the length of high heeled shoes used by women (p value= 0.03<0.05). A positive association was also found between an occurrence of upper back discomfort and length of the heeled shoes (p value= 0.01<0.05). However, no significant association was found between pain intensity and length of the shoe' heel, frequency and duration of high heeled shoe use. Conclusion: The shoulders' and upper back discomfort in females who frequently used high heeled shoes was associated with the length of the heels in shoes. Keywords: Female, Heel, Musculoskeletal System, Pain, Shoes. (JPMA 70: 2199; 2020) DOI: https://doi.org/10.47391/JPMA.536 Department of Physical Therapy, Shifa Tameer e Millat University, Islamabad, Pakistan. Correspondence: Wardah Hussain Malick. Email: wardahmalick@gmail.com