Long-term use of high-heeled shoes alters the neuromechanics of human walking

Transient pain and discomfort when wearing high-heeled shoes

In the dynamic world of fashion, high-heeled footwear is revered as a symbol of style, luxury and sophistication. Yet, beneath the facade of elegance of classy footwear lies the harsh reality of discomfort and pain. Thus, this study aims to investigate the influence of wearing high-heeled shoes on the sensation of pain across different body regions over a period of 6 h. It involved fifty female participants, all habitual wearers of high-heeled shoes, aged between 20 and 30 years. Each participant kept a record of their perceptions of pain and discomfort every hour for a total of 6 h using a 0-10 pain scale with 0 indicating no pain and 10 indicating severe pain. The findings reveal a progressive rise in pain throughout wear, with the most intense pain reported in the back, calcaneus, and metatarsals. The analysis shows that after approximately 3.5 h, participants experience significant increases in pain levels. However, the relationship between heel height and pain is not linear. It appears that a heel height of 7.5 cm is the threshold where overall body pain becomes significant. The study suggests that a duration of 3.5 h of wear and a heel height of 7.5 cm serve as critical points to decrease overall body pain. Moreover, beyond this heel height, knee pain diminishes compared to other body areas possibly due to the shift towards a more neutral posture. The study findings, coupled with the recommendations, can assist footwear designers in crafting not only stylish but also comfortable shoes.

Habitually wearing high heels may improve user walking economy in any footwear

The habitual use of high-heeled footwear may structurally remodel user leg muscle tendons, thereby altering their functional capabilities. High heels set users' ankles in relatively plantarflexed positions, causing calf muscle tendons to operate at relatively short lengths. Habitually operating muscle tendons at relatively short lengths induces structural remodeling that theoretically affects muscle metabolism. Because structural changes occur within the body, the user's locomotor metabolism may change in any footwear condition (e.g., conventional shoes, barefoot). Here, we studied the influence of habitual high-heel use on users' leg muscle-tendon structure and metabolism during walking in flat-soled footwear. We tested eight participants before and after 14 wk of agreeing to wear high heels as their daily shoes. Overall, participants who wore high heels >1,500 steps per day, experienced a 9% decrease in their net metabolic power during walking in flat-soled footwear (d = 1.66, P ≤ 0.049), whereas participants who took <1,000 daily steps in high heels did not (d = 0.44; P = 0.524). Across participants, for every 1,000 daily steps in high heels, net metabolic power during walking in flat-soled footwear decreased 5.3% (r = -0.73; P = 0.040). Metabolic findings were partially explained (r2 = 0.43; P = 0.478) by trending shorter medial gastrocnemius fascicle lengths (d = 0.500, P = 0.327) and increased Achilles tendon stiffness (d = 2.889, P = 0.088). The high-heel intervention did not alter user walking stride kinematics in flat-soled footwear (d ≤ 0.567, P ≥ 0.387). While our limited dataset is unable to establish the mechanisms underlying the high-heel-induced walking economy improvement, it appears that prescribing specific footwear use can be implemented to alter user muscle-tendon properties and augment their function in any shoes.NEW & NOTEWORTHY Habitually wearing high-heeled footwear structurally remodels leg muscle tendons and improves user walking economy, regardless of worn attire.

The Effect of Walking in High Heels on the Activation and Deactivation of Upper Trunk Muscles

The aim of the study was to investigate how high-heeled walking affects the coordination changes of timing of upper trunk muscle activation, and the possible occurrence of health problems in this part of the body of young women. We used surface electromyography (EMG) for data collection. The research group consisted of 30 women. Statistical significance of the changes in muscle coordination was confirmed when evaluating two of the four upper trunk muscles studied. M. trapezius and m. pectoralis major are not subject to changes in gait in high heels (HH) from the point of view of timing on a statistical level, but HH increase the intensity of muscle contraction of all monitored muscles, and therefore we recommend limiting the wearing of HH in case of health problems related to these muscles.

Effects of Midsole Hardness on the Mechanical Response Characteristics of the Plantar Fascia during Running

High long-term stress on the plantar fascia (PF) is the main cause of plantar fasciitis. Changes in the midsole hardness (MH) of running shoes are an important factor leading to the alteration of the PF. This study aims to establish a finite-element (FE) model of the foot-shoe, and investigates the effects of midsole hardness on PF stress and strain. The FE foot-shoe model was built in ANSYS using computed-tomography imaging data. Static structural analysis was used to simulate the moment of running push and stretch. Plantar stress and strain under different MH levels were quantitatively analyzed. A complete and valid 3D FE model was established. With an increase in MH from 10 to 50 Shore A, the overall stress and strain of the PF were decreased by approximately 1.62%, and the metatarsophalangeal (MTP) joint flexion angle was decreased by approximately 26.2%. The height of the arch descent decreased by approximately 24.7%, but the peak pressure of the outsole increased by approximately 26.6%. The established model in this study was effective. For running shoes, increasing the MH reduces the stress and strain of PF, but also imposes a higher load on the foot.

Effects of high-heeled shoes on lower extremity biomechanics and balance in females: a systematic review and meta-analysis

BACKGROUND

High-heeled shoes (HHS) are widely worn by women in daily life. Limited quantitative studies have been conducted to investigate the biomechanical performance between wearing HHS and wearing flat shoes or barefoot. This study aimed to compare spatiotemporal parameters, kinematics, kinetics and muscle function during walking and balance between wearing HHS and flat shoes or barefoot.

METHODS

According to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement, PubMed Medline, Cochrane, EMBASE, CINAHL Complete and Web of Science databases were searched from the earliest record to December 2021. A modified quality index was applied to evaluate the risk of bias, and effect sizes with 95% confidence intervals were calculated as the standardized mean differences (SMD). Potential publication bias was evaluated graphically using funnel plot and the robustness of the overall results was assessed using sensitivity analyses.

RESULTS

Eighty-one studies (n = 1501 participants) were included in this study. The reduced area of support requires the body to establish a safer and more stable gait pattern by changing gait characteristics when walking in HHS compared with walking in flats shoes or barefoot. Walking in HHS has a slight effect on hip kinematics, with biomechanical changes and adaptations concentrated in the knee and foot-ankle complex. Females wearing HHS performed greater ground reaction forces earlier, accompanied by an anterior shift in plantar pressure compared with those wearing flat shoes/barefoot. Furthermore, large effect sizes indicate that wearing HHS resulted in poor static and dynamic balance.

CONCLUSION

Spatiotemporal, kinematic, kinetic and balance variables are affected by wearing HHS. The effect of specific heel heights on women's biomechanics would benefit from further research.

Shorter muscle fascicle operating lengths increase the metabolic cost of cyclic force production

During locomotion, force-producing limb muscles are predominantly responsible for an animal's whole body metabolic energy expenditure. Animals can change the length of their force-producing muscle fascicles by altering body posture (e.g., joint angles), the structural properties of their biological tissues over time (e.g., tendon stiffness), or the body's kinetics (e.g., body weight). Currently, it is uncertain whether relative muscle fascicle operating lengths have a measurable effect on the metabolic energy expended during cyclic locomotion-like contractions. To address this uncertainty, we quantified the metabolic energy expenditure of human participants, as they cyclically produced two distinct ankle moments at three ankle angles (90°, 105°, and 120°) on a fixed-position dynamometer using their soleus. Overall, increasing participant ankle angle from 90° to 120° (more plantar flexion) reduced minimum soleus fascicle length by 17% (both moment levels, P < 0.001) and increased metabolic energy expenditure by an average of 208% across both moment levels (both P < 0.001). For both moment levels, the increased metabolic energy expenditure was not related to greater fascicle positive mechanical work (higher moment level, P = 0.591), fascicle force rate (both P ≥ 0.235), or model-estimated active muscle volume (both P ≥ 0.122). Alternatively, metabolic energy expenditure correlated with average relative soleus fascicle length (r = -0.72, P = 0.002) and activation (r = 0.51, P < 0.001). Therefore, increasing active muscle fascicle operating lengths may reduce metabolic energy expended during locomotion.NEW & NOTEWORTHY During locomotion, active muscles undergo cyclic length-changing contractions. In this study, we isolated confounding variables and revealed that cyclically producing force at relatively shorter fascicle lengths increases metabolic energy expenditure. Therefore, muscle fascicle operating lengths likely have a measurable effect on the metabolic energy expenditure during locomotion.

Effectiveness of mechanical treatment with customized insole and minimalist flexible footwear for women with calcaneal spur: randomized controlled trial

BACKROUND

Calcaneal spurs are described as bony outgrowths arising on medial calcaneal, where inappropriate footwear can promote disease progression.

OBJECTIVE

Investigate the effectiveness of mechanical treatment with customized insole and minimalist flexible footwear during gait training program in women with calcaneal spur.

METHODS

Design: A single-blinded, randomized and controlled trial.

SETTING

Biomechanics laboratory.

PARTICIPANTS

Forty-three women, 29 with calcaneal spur and 14 control.

INTERVENTION

Gait training program with use of the minimalist flexible footwear (MFG n = 15, age: 48.9 ± 9.4, height: 1.61 ± 0.1, BMI: 32.1 ± 7.0) and customized insole on footwear (COIG n = 14, age: 50.3 ± 5.8, height: 1.62 ± 0.1, BMI: 32.2 ± 4.3) and control (CG n = 14, age: 47.8 ± 8.6, height: 1.63 ± 0.1, BMI: 27.5 ± 4.5), followed of the evaluations: baseline (T0) and after three (T3) and six (T6) months. Duration of the intervention was of the six months consecutive for at least 42 h per week (six hours a day, seven days a week). Outcome primary were calcaneus pain (visual analogue scale), Foot Function Index (FFI), Foot Health Status Questionnaire (FHSQ-Br) and 6-min walk test (6MWT). Secondary was plantar pressure distribution by a pressure platform system during gait and static index foot posture (FPI).

STATISTICAL ANALYSIS

analysis of variance for repeated measure and between groups were used to detect treatment-time interactions (α = 5%). Effect size with D Cohen's also was used between T0 and after six (T6) months of intervention.

RESULTS

The MFG and COIG were effective at reducing pain after six months (MFG: 2.5-4.5 CI, p = 0.001; COIG: 1.5-3.5 CI, p = 0.011). The FFI and FHSQ-Br showed improvements with MFG and COIG after T6 (MFG: 13.7-15.4 CI, p = 0.010; COIG: 11.3-15.0 CI, p = 0.001). The 6MWT increased with MFG (589.3-622.7 CI) and COIG (401.3-644.7 CI) and foot pronation was decreased after T3 and T6 MFG (FPI Right: 4.2-5.4 CI; Left: 3.6-5.4 CI) COIG (FPI Right: 3.4-6.8 CI; Left: 3.3-5.7 CI). The contact area reduced on forefoot and rearfoot with MFG and GOIG and midfoot and rearfoot with MFG. Maximum force was reduced on foot with MFG after T3 and T6. The peak pressure was reduced on the forefoot with MFG and COIG and on midfoot and rearfoot with MFG.

CONCLUSIONS

The mechanical treatment with customized insole and minimalist flexible footwear during gait training program during six months in women with calcaneal spur reduced the calcaneus pain, increased function and health feet and reduced plantar load on the rearfoot, midfoot and forefoot. However, the footwear alone was more effective than when combined customized insole, given the greater efficacy on clinical and biomechanical aspects.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03040557 (date of first registration: 02/02/2017).

Relationships between the Perception of Footwear Comfort and the Fear of Falls in People at the Early Period of Old Age

Objective: The present study aimed to analyze the relationships between the perceptions of footwear comfort with fear of falls in younger-old women and men. Participants: the population sample involved 100 free-living community dwellers aged 65−74. Design: the Falls Efficacy Scale-International and a visual analogue scale to assess perception of footwear comfort were used as research tools. Results: there were statistically significant differences in the FES-I results in people who suffered a fall in the last year compared to those who did not experience a fall (p < 0.001), as well as in the subjective assessment of mediolateral control in people who have suffered and have not suffered a fall in the last year (p = 0.033). In women, statistically significant relationships were found in the subjective assessment of shoe comfort in terms of arch height (p = 0.025) and material properties of the footwear (p = 0.036) with the results of FES-I. Conclusions: People who have fallen show a higher level of fear of falling. The assessment of footwear comfort in terms of mediolateral control was lower in the younger-old who had experienced a fall in the last year. In women, a worse assessment of arch height and material properties of the footwear is accompanied by greater fear of falling.

Effects of Occasional and Habitual Wearing of High-Heeled Shoes on Static Balance in Young Women

The purpose of this study was to examine the effects of occasional and habitual wearing of high-heeled shoes on static balance in young women. Groups of habitual high-heel wearers and non-wearers (n = 7 in both groups) were asked to stand quietly on a force platform without shoes (WS condition) or with high heels (heel area 1 cm², heel height 7 cm) (HH condition). During the trials, the center-of-pressure (CoP) position in the anterior-posterior direction was measured, and its root mean square (as a measure of postural sway magnitude, CoP_RMS) and mean velocity (as a measure of regulatory activity, CoP_MV) were calculated. To further examine the effect of high-heel wearing on the temporal aspects of slow and fast processes in static balance, the CoP sway was decomposed into low- (below 0.5 Hz) and high- (above 0.5 Hz) frequency components, and then spectral analysis was performed. Results showed that the CoP_RMS was not significantly different between the groups or between the shoe conditions, indicating that wearing high heels with a heel height of 7 cm did not increase the magnitude of postural sway, irrespective of high-heel experience. The CoP_MV was significantly larger in the HH condition than in the WS condition, whereas it was not significantly different between the groups. This result indicates that wearing high heels increased the amount of regulatory activity in both habitual wearers and non-wearers. The spectral analysis further showed that habitual high-heel wearers showed significantly decreased rate of regulatory activity than non-wearers, both while standing with and without high heels. These results suggest that use-dependent changes in static balance control are evident in both high-heeled and without shoes conditions.

Perception of footwear comfort and its relationship with the foot structure among youngest-old women and men

Background

Adequate footwear comfort and functionality are important regardless of age, but they become particularly important in the youngest-old women and men, mainly due to the fact that this age range is the initial period of old age with changes in shoe preferences. The aim of this study was to assess the perception of footwear comfort and its relationship with the feet structure in youngest-old women and men.

Methods

The cross-sectional study covered community dwellers living on their own aged 65–74 years (50 women; 50 men). The feet characteristics were measured using the CQ-ST podoscope (Electronic System, Ltd, EU), and the perception of footwear comfort was assessed with a visual analogue scale. The assessment took into account gender-specific footwear of a certain brand (Befado Dr orto).

Results

Statistically significant intergender differences were observed in the perception of footwear comfort with respect to the shoe heel width (p = 0.022), the arch height (p = 0.013), the overall comfort (p = 0.049) and the material properties of the footwear (p = 0.017). In women, there were statistically significant positive relationships among the heel angle (γ) and the perception of footwear comfort in terms of heel cushioning (p = 0.021), forefoot cushioning (p = 0.015), arch height (p = 0.029). In men, there was a statistically significant negative relationship of the left foot Clarke’s angle with the heel height (p = 0.043), and a positive relationship between the right foot width and the arch height (p = 0.044).

Conclusions

Youngest-old women, compared to men of the same age range, have a higher perception of shoe comfort in terms of the shoe heel width, the arch height, the overall comfort of the footwear and the material properties of the footwear. The appropriate profile and construction of the shoe allows for an increase in the contact surface of the foot with the shoe, hence the improvement in the perception of footwear comfort in people with lowered arch or widened forefoot.

Substantial Achilles adaptation following strength training has no impact on tendon function during walking

Tendons are responsive to mechanical loading and their properties are often the target of intervention programs. The tendon's mechanical properties, particularly stiffness, also govern its function, therefore changes to these properties could have substantial influence on energy-saving mechanisms during activities utilizing the stretch-shortening cycle. We investigated Achilles tendon (AT) function in vivo during walking with respect to a training intervention that elicited significant increases in AT stiffness. 14 men and women completed 12-weeks of isometric plantarflexor strength training that increased AT stiffness, measured during isometric MVC, by ~31%. Before and after the intervention, participants walked shod at their preferred velocity on a fully-instrumented treadmill. Movement kinematics, kinetics and displacement of the gastrocnemius medialis muscle-tendon junction were captured synchronously using 3D motion capture and ultrasound imaging, respectively. A MANOVA test was used to examine changes in AT force, stress, strain, stiffness, Young's modulus, hysteresis and strain energy, measured during walking, before and following strength training. All were non-significant for a main effect of time, therefore no follow-up statistical tests were conducted. Changes in joint kinematics, tendon strain, velocity, work and power and muscle activity during the stance phase were assessed with 1D statistical parametric mapping, all of which also demonstrated a lack of change in response to the intervention. This in vivo examination of tendon function in walking provides an important foundation for investigating the functional consequences of training adaptations. We found substantial increases in AT stiffness did not impact on tendon function during walking. AT stiffness measured during walking, however, was unchanged with training, which suggests that increases in stiffness may not be evident across the whole force-elongation relation, a finding which may help explain previously mixed intervention results and guide future investigations in the functional implications of tendon adaptation.

Impact of high-heeled and sport shoes on multi-joint external load profile during walking

BACKGROUND

Previous studies have analysed the effect of wearing high-heeled shoes (HHS) on gait analysis, balance and its relation to health. However, further research is needed to study its effect on the difference of chain reactions in the transfer of body impacts from the lower to the upper limbs.

OBJECTIVES

The aims of the present research were: (a) to compare the effects of wearing HHS on impacts across body joints during walking with sport shoes (SS) as a reference, and (b) to examine such effects at different speeds.

METHODS

Seven well-trained women completed this study. Incremental treadmill walking test were performed with two different footwear: SS and HHS. Inertial devices were used to quantify the chain reactions at selected anatomical lower limbs and trunk locations. Statistical analysis included the Wilcoxon test with ranges and Cohen's d effect size with percentage of differences.

RESULTS

The highest values were found at the heel in both footwear and in both legs (SS: right =0.76 ± 0.27, left = 0.79 ± 0.27; HHS: right = 1.07 ± 0.38, left = 1.11 ± 0.41), while the lowest values were registered at lower and upper back. Furthermore, significant differences were found with the HHS load being higher at all locations (p< 0.05; %=𝑑𝑖𝑓𝑓 12.20-36.36%), influenced by the walking speed. In addition, a strong influence of footwear in the change of the laterality profile was found (p< 0.05).

CONCLUSIONS

These findings suggest that the use of HHS increase the load on the lower limb and the trunk. Until reaching 5 km/h during walking, no significant differences were found between wearing HHS or SS in accelerometer load, producing exponential differences from this speed. The great between-subject variability implies that within-subject analysis is recommended, as it is more related to real clinical practice.

The effects of wearing high heeled shoes on the muscles and joints of lower limb

Study aim: The aim of this study is to investigate whether the lower extremity muscles’ force/torque/strength and range of motion may be affected in females wearing high heeled shoes and not wearing high heeled shoes.

Material and methods: The study was carried out with 136 females aged between 18 and 45 years. The first group consisted of 66 females wearing 5 cm or higher high heeled shoes. The second group consisted of 70 females wearing shoes having heel height less than 5 cm. The Nicholas Manual Muscle Tester was used to evaluate lower extremity muscle force/torque/strength, while range of motion was assessed with an electronic goniometer. The SPSS 21.0 program was used for statistical analysis.

Results: A significant difference was found in the lower extremity muscles’ force (except for hip adduction, dorsiflexion, metatarsophalangeal joint and interphalangeal joint extension), and muscles’ torque (except for hip adduction, dorsiflexion and left tibialis anterior muscle) and muscles’ strength values (except for hip adduction, dorsiflexion and tibialis anterior muscle). Also, as heel height increased, the range of motion of hip joint flexion, internal rotation and plantar flexion increased significantly.

Conclusions: Excessive use of high heeled shoes can cause changes in muscle force/torque/strength and joint range of motion.

Health View to Decrease Negative Effect of High Heels Wearing: A Systemic Review

Effective recommendations about how to decrease adverse effects of high heels (HH) need to be provided, since wearing HH is inevitable for most women in their daily life, regardless of their negative impacts on the foot morphology. The main purpose of this systematic review was to summarize studies which have provided specific information about how to effectively offset the negative effects of wearing HH, in the case of women, by means of examining heel height, insole, and heel base support (HBS). Some evidence indicate the following: (i) the range of appropriate heel height for HH shoes is 3.76 cm to 4.47 cm; (ii) compared to small HBS, the larger ones effectively increase gait stability, reduce risk of ankle injury, and improve comfort rating during HH walking; and (iii) the use of a total contact insert (TCI) significantly decreases plantar pressure and the impact on the foot, resulting in higher perceived comfort. It must be noted that these results are based on short-term research; therefore, any conclusions with regard to effects in the long term should be taken with a grain of salt. Nevertheless, future studies should be aimed at combining numerical and experimental methods, in order to provide personal recommendations for HH shoes by considering heel height and HBS size, based on the individual characters (weight, height, and age).

Increased knee flexion and varus moments during gait with high-heeled shoes: A systematic review and meta-analysis

BACKGROUND

High-heeled shoes have been thought to alter lower extremity joint mechanics during gait, however its effects on the knee remain unclear.

RESEARCH QUESTION

This systematic review and meta-analysis aimed to determine the effects of high-heeled shoes on the sagittal- and frontal-plane knee kinetics/kinematics during gait.

METHODS

1449 studies from 6 databases were screened for the following criteria: 1) healthy adult females, 2) knee joint kinematics/kinetics reported for the early stance phase during gait under varying shoe heel heights (including barefoot). Excluded studies included those mixing different shoe styles in addition to altering the heel heights. A total of 14 studies (203 subjects) met the selection criteria, resulting in 51 and 21 Cohen's d effect sizes (ESs) comparing the differences in knee sagittal- (flexion) and frontal-plane (varus) moment/angle, respectively, between shoes with higher heels and shoes with lower heels/barefoot.

RESULTS

Meta-analyses yielded a significant medium-to-large effect of higher heels compared to lower heels on increasing knee flexion moment (overall ES = 0.83; P < 0.01), flexion angle (overall ES=0.46; P < 0.01), and varus moment (overall ES=0.52; P < 0.01) during the early stance phase of gait. The results of meta-regressions used to explore factors explaining the heterogeneity among study ESs revealed that a greater ES in the knee flexion moment was associated with an elevated heel height of the high-heeled shoes (P = 0.02) and greater body mass of the individuals (P = 0.012). A greater ES in the knee varus moment during high-heeled gait was associated with a greater body height (P = 0.003) and mass (P = 0.006).

SIGNIFICANCE

Given the association between increased knee flexion/varus moments and risk of developing knee osteoarthritis (OA), women who wear high-heel shoes frequently and for a long period may be more susceptible to knee OA. Preventive treatments, such as lower extremity muscle strengthening, may help improve shock absorption to decrease knee loading in high-heel users.

A center of pressure progression model for walking with non heeled and heeled footwear

BACKGROUND

Heeled footwear benefits people with movement disorder in the form of shoe lifts, wedges and inserts while its prolonged use causes foot injury in healthy people. There lies a need to detect parameters that affect COP progression of the foot and gait stability due to footwear.

RESEARCH QUESTION

Do we have bipedal models that can estimate gait parameters corresponding to different center of pressure (COP) trajectories?

METHOD

In this study, we propose a COP translation model that can account for non heeled to heeled footwear. We describe the COP progression as a function of the center of mass (COM) state. This model is used to generate stable steady state walking solutions for different COP profiles. We compare these model solutions with experimental data on non-heeled and heeled-gait.

RESULTS

The bipedal model shows stability across different COP profiles. The model estimates GRF profile (R²=0.83 for 1.3 m/s ) for non heeled normal walking qualitatively and on the temporal scale. It estimates GRF due to heeled gait (R²=0.83 for 1.08 m/s) but is limited in estimation of heeled gait parameters.

SIGNIFICANCE

A bipedal model that can generate stable steady state walking solutions for different forward progressing COP profiles can help in design of foot orthotics for patients with gait disorder and understand injuries occurring due to prolonged wear of rigid heeled footwear.

Muscle Activity of the Triceps Surae With Novel Propulsion Heel-Lift Orthotics in Recreational Runners

Background:

The triceps surae muscle has been identified with propulsion during running gait, and typical heel-lift orthotics (THOs) have been used to treat some sports injuries of this structural-biomechanical unit. The effects of a novel propulsion heel-lift orthotic (PHO) on surface electromyography (EMG) activity of the gastrocnemius during a full cycle of running have yet to be tested.

Purpose/Hypothesis:

We aimed to assess EMG changes in gastrocnemius medialis and lateralis muscle activity when wearing THOs, PHOs, or neutral sports shoes only (SO) during running. We hypothesized that EMG activity of the triceps surae muscle would be lower for PHOs than THOs or SO during running.

Study Design:

Controlled laboratory study.

Methods:

A total of 26 healthy, regular recreational runners of both sexes (mean age, 33.58 ± 6.02 years) with a neutral Foot Posture Index and rearfoot strike pattern were recruited to run on a treadmill at 9 km/h using aleatory THOs of 6 and 9 mm, PHOs, and SO while EMG activity of the gastrocnemius medialis and lateralis muscles was recorded over a 30-second period. Intraclass correlation coefficients were calculated to assess reliability.

Results:

The intraclass correlation coefficient values indicated near perfect reliability, ranging from 0.801 for 6-mm THOs to 0.959 for SO in the gastrocnemius lateralis muscle. EMG activity of the gastrocnemius lateralis muscle was greater for PHOs (25.516 ± 4.780 mV) than for SO (23.140 ± 4.150 mV) (P < .05), but EMG activity of the gastrocnemius medialis muscle did not show any statistically significant difference between conditions (23.130 ± 2.980 mV vs 26.315 ± 2.930 mV, respectively) (P = .3).

Conclusion:

A novel PHO may increase muscle activity of the gastrocnemius lateralis during a full cycle of running gait; consequently, its prescription to treat triceps surae muscle injuries is cautioned.

Clinical Relevance:

The prescription of novel PHOs could increase EMG activity, which has not been previously described.

Influences of heel height on human postural stability and functional mobility between inexperienced and experienced high heel shoe wearers

Background

High heel shoes (HHS) can affect human postural control because elevated heel height (HH) may result in plantar flexed foot and limit ankle joint range of motion during walking. Effects of HH and HHS wearing experience on postural stability during self-initiated and externally triggered perturbations are less examined in the literature. Hence, the objective of the present study is to investigate the influences of HH on human postural stability during dynamic perturbations, perceived stability, and functional mobility between inexperienced and experienced HHS wearers.

Methods

A total of 41 female participants were recruited (21 inexperienced HHS wearers and 20 experienced HHS wearers). Sensory organization test (SOT), motor control test (MCT), and limits of stability (LOS) were conducted to measure participant’s postural stability by using computerized dynamic posturography. Functional reach test and timed up and go test were performed to measure functional mobility. The participants’ self-perceived stability was assessed by visual analog scale. Four pairs of shoes with different HH (i.e., 0.8, 3.9, 7.0, and 10.1 cm) were applied to participants randomly. Repeated measures analysis of variance was conducted to detect the effects of HH and HHS wearing experience on each variable.

Results

During self-initiated perturbations, equilibrium score remarkably decreased when wearing 10.1 cm compared with flat shoes and 3.9 cm HHS. The contribution of vision to postural stability was larger in 10.1 cm HHS than in flat shoes. The use of ankle strategy worsened when HH increased to 7 cm. Similarly, the directional control of the center of gravity (COG) decreased for 7 cm HHS in LOS. Experienced wearers showed significantly higher percentage of ankle strategy and COG directional control than novices. Under externally triggered perturbations, postural stability was substantially decreased when HH reached 3.9 cm in MCT. No significant difference was found in experienced wearers compared with novices in MCT. Experienced wearers exhibited considerably better functional mobility and perceived stability with increased HH.

Conclusions

The use of HHS may worsen dynamic postural control and functional mobility when HH increases to 3.9 cm. Although experienced HHS wearers exhibit higher proportion of ankle strategy and COG directional control, the experience may not influence overall human postural control. Sensory organization ability, ankle strategy and COG directional control might provide useful information in developing a safety system and prevent HHS wearers from falling.

Shoes and Insoles: The Influence on Motor Tasks Related to Walking Gait Variability and Stability

The rhythmic control of the lower limb muscles influences the cycle-to-cycle variability during a walking task. The benefits of insoles, commonly used to improve the walking gait, have been little studied. Therefore, the aim of this study was to assess the walking gait variability and stability on different walking conditions (without shoes, WTS, with shoes, WS, with shoes and insoles, WSI) related to brain activity. Twelve participants randomly (WTS/WS/WSI) walked on a treadmill at 4 km/h for 10 min. Kinematic analysis (i.e., footstep and gait variability), brain activation (beta wave signal), rating of perceived exertion (RPE, CR-10 scale), and time domain measures of walking variability were assessed. The maximum Lyapunov exponent (LyE) on the stride cycle period's datasets was also calculated. Stride length and cycle calculated for all walking conditions were 61.59 ± 2.53/63.38 ± 1.43/64.09 ± 2.40 cm and 1.11 ± 0.03/1.14 ± 0.03/1.15 ± 0.04 s (F_1,10 = 4.941/p = 0.01, F_1,10 = 4.938/p = 0.012) for WTS, WS, WSI, respectively. Beta wave (F_1,10 = 564.201/p = 0.0001) was higher in WTS compared to WS and WSI. Analysis of variance's (ANOVA) LyE showed a F_1,10 = 3.209/p = 0.056, while post hoc analysis showed a significant effect between WS and WSI with p = 0.023, and nonsignificant effects between WTS and WS/WSI (p = 0.070/0.607), respectively. Small perturbations of the foot can influence the control of gait rhythmicity by increasing the variability in a dissipative deterministic regimen.

Do habitual foot-strike patterns in running influence functional Achilles tendon properties during gait?

The capacity of foot-strike running patterns to influence the functional properties of the Achilles tendon is controversial. This study used transmission-mode ultrasound to investigate the influence of habitual running foot-strike pattern on Achilles tendon properties during barefoot walking and running. Fifteen runners with rearfoot (RFS) and 10 with a forefoot (FFS) foot-strike running pattern had ultrasound transmission velocity measured in the right Achilles tendon during barefoot walking (≈1.1 ms^-1) and running (≈2.0 ms^-1). Temporospatial gait parameters, ankle kinematics and vertical ground reaction force were simultaneously recorded. Statistical comparisons between foot-strike patterns were made using repeated measure ANOVAs. FFS was characterised by a significantly shorter stance duration (-4%), greater ankle dorsiflexion (+2°), and higher peak vertical ground reaction force (+20% bodyweight) than RFS running (P < .05). Both groups adopted a RFS pattern during walking, with only the relative timing of peak dorsiflexion (3%), ground reaction force (1-2%) and peak vertical force loading rates (22-23%) differing between groups (P < .05). Peak ultrasound transmission velocity in the Achilles tendon was significantly higher in FFS during walking (≈100 ms^-1) and running (≈130 ms^-1) than RFS (P < .05). Functional Achilles tendon properties differ with habitual footfall patterns in recreational runners.

Relationship between medial gastrocnemius muscle stiffness and the angle between the rearfoot and floor

The present study examined the stiffness in the medial gastrocnemius muscle at various angles between the rearfoot and the floor. Six healthy young men participated in the study. A triangle support was attached to the force plate. Each participant placed their forefoot and rearfoot onto the force plate and the triangle support, respectively. Electrical stimulation was applied to the medial gastrocnemius muscle using Ag-AgCl surface electrodes. The center of pressure was measured with the force plate, and electrically-induced fluctuation of the center of pressure was extracted using a Kalman filter. Measurements were performed at 10°, 20°, and 30°angles of the triangle support. The transfer function from the stimulation to the fluctuation was identified, and the poles of the transfer function were used to estimate the medial gastrocnemius muscle and ankle stiffness. The muscle stiffness increased as the angle of the triangle support increased.

Effects of High-Frequency Proprioceptive Training on Single Stance Stability in Older Adults: Implications for Fall Prevention

Single-limb stance instability is a major risk factor for falls in older adults. Thus, improvement of stance stability could play an important role in fall prevention. This study aimed to determine whether high-frequency proprioceptive training (HPT) could significantly improve single stance stability (SSS) in older adults, by increasing proprioceptive control and optimizing the contribution of vision. Sixty-one subjects (30 men, 31 women) aged 65-85 years were investigated. The subjects were randomly assigned to three intervention groups, i.e., HPT, treadmill, and no intervention, stratifying by gender and proprioceptive control at baseline. Stability tests and HPT, consisting of 12 sessions (6 weeks), were performed with computerized postural stations. Pre-post analysis showed that HPT significantly improved SSS by increasing proprioceptive control (p<0.001) and postural control (p<0.01). The treadmill and no intervention groups did not show any significant change. The results showed that different levels of proprioceptive control may activate, inhibit, or minimize the stabilizing intervention of vision. Given that HPT significantly reduced ankle sprains and low back pain in professional athletes (previous study), we discuss the hypothesis that the risk of falls in older adults and the risk of recurrent injuries in athletes would have a common origin: lack of proprioceptive control consequent to reduced interaction with uneven ground. The findings suggest that HPT may be a powerful activator of refined proprioceptive control, which allows increased SSS, safer interaction with the ground, and mitigation of other risk factors.

Heel Height as an Etiology of Hallux Abductus Valgus Development: An electromagnetic Static and Dynamic First Metatarsophalangeal Joint Study

Background: Hallux abductus valgus (HAV) is a forefoot condition produced by extrinsic and intrinsic factors. Shoes with a high heel height and a typical narrow tip toe box can induce deviations in both the proximal phalanx of the hallux (PPH) and the first metatarsal (IMTT) bones. Nevertheless, the isolated role of heel height remains unclear in the development of HAV pathology. Objectives: The goal was to determine if the heel height increase of shoes without a narrow box toe could augment the PPH and IMTT deviation in frontal, sagittal, and transverse planes toward the first metatarsophalangeal joint (MPJ) and the first metatarsocuneiform joint (MCJ), respectively, during static and dynamic conditions in relation to precursor movements of HAV. Methods: Women with an average age of 25.10 ± 4.67 years were recruited in this cross-sectional study to assess the three planes of motion of PPH and IMTT while wearing high heels with heights at 3, 6, 9 cm and unshod conditions via sandals. The measurements used an electromagnetic goniometer device with sensors placed on medial aspects of the PPH and IMTT bones under static and dynamic conditions. Results: Wearing shoes with a 6 cm heel in dynamic condition may increase the PPH valgus and abduction deviation from 3.15 ± 0.10° to 3.46 ± 0.05° (p < 0.05) and from 1.35 ± 0.28° to 1.69 ± 0.30° (p < 0.001), respectively. In addition, a PPH abduction increase from 1.01 ± 0.36° to 1.31 ± 0.46° (p < 0.05) after wearing shoes with a 6 cm heel height was observed under static conditions. Conclusions: Wearing shoes with a heel height of 6 cm without a narrow box toe interference may produce PPH abduction and valgus deviations related to HAV formation.

Ultrasonographic Evaluation of the Femoral Cartilage, Achilles Tendon, and Plantar Fascia in Young Women Wearing High-Heeled Shoes

BACKGROUND

Specific attention on the musculoskeletal impact of wearing high-heeled shoes (HHS) has mainly focused on knee osteoarthritis and the literature is limited to biomechanical changes. The distal femoral cartilage has not been morphologically studied. Additionally, although heel elevation is coupled with a shear stress at the heel and overloaded calf muscles, Achilles tendon (AT) and plantar fascia (PF) thicknesses have not been assessed either.

OBJECTIVE

To investigate whether the distal femoral cartilage, AT, and PF were different in women wearing HHS and flat-heeled shoes (FHS) and specifically, different in terms of AT/PF and distal femoral cartilage thicknesses.

DESIGN

Cross-sectional observational study.

SETTING

Tertiary care center.

PARTICIPANTS

There were 34 women (mean age; 31.1 ± 6.4, body mass index [BMI]; 21.6 ± 2.4 kg/m² ) in the HHS group and 54 women (mean age; 29.5 ± 7.2 years, BMI 22.5 ± 2.9 kg/m² ) in the FHS group (P = .271, P = .102, respectively). Women wearing shoes with a heel height of >5 cm were enrolled in the HHS group, and those wearing shoes with a heel height of <1.4 cm were included in the FHS group.

MAIN OUTCOME MEASUREMENTS

Distal femoral cartilage from the lateral condyle, intercondylar area and medial condyle (MFC), AT and PF thicknesses, and any abnormalities were evaluated bilaterally by ultrasound.

RESULTS

Within-group comparisons yielded thicker right MFC (P = .022) and left AT (P = .028) only in the HHS group. Between-group comparisons yielded thicker left AT in the HHS group (P = .040). PF thicknesses were similar both within and between group comparisons (all P > .05). Right AT thickness was positively correlated with right (r = .469, P = .005) and left (r = .402, P = .018) PF thicknesses only within the HHS group. Only calcaneal irregularity/spur was found to be common in the HHS group (P = .038).

CONCLUSIONS

We found thickening of the right MFC and left AT in those wearing HHS, whereas PF thickness was not significantly different between those wearing HHS and those wearing FHS.

LEVEL OF EVIDENCE

III.

Falls, Footwear, and Podiatric Interventions in Older Adults

Footwear is a modifiable risk factor for falls in older adults, including populations with metabolic disease, inflammatory arthritis, and neurodegenerative disease. Ill-fitting footwear, and specific design features, such as elevated heels and backless styles, can impair balance control and heighten the risk of falling. Although foot care is routine practice for some older adults to prevent ulceration (eg, diabetes) or relieve symptoms (eg, foot pain), new footwear interventions are emerging with the potential to ameliorate balance and walking impairments. Multifaceted podiatric interventions, which include appropriate footwear and importantly patient education, may have the capacity to reduce falls in older adults.

Analysis of foot kinematics wearing high heels using the Oxford foot model

Wearing high heels is thought to lead to various foot disorders and injuries such as metatarsal pain, Achilles tendon tension, plantar fasciitis and Haglund malformation. However, there is little available information explaining the specific mechanisms and reasons why wearing high heels causes foot deformity. Therefore, the purpose of this study was to investigate the foot kinematics of high heel wearers and compare any differences with barefoot individuals using the Oxford Foot Model (OFM). Fifteen healthy women aged 20-25 years were measured while walking barefoot and when wearing high heels. The peak value of angular motion for the hallux with respect to the forefoot, the forefoot with respect to the hind foot, and the hind foot with respect to the tibia were all analyzed. Compared to the barefoot, participants wearing high heels demonstrated larger hallux dorsiflexion (22.55∘± 1.62∘ VS 26.6∘± 2.33∘ for the barefoot; P= 0.001), and less hallux plantarflexion during the initial stance phase (-4.86∘± 2.32∘ VS -8.68∘± 1.13∘; P< 0.001). There were also greater forefoot adduction (16.15∘± 1.37∘ VS 13.18∘± 0.79∘; P< 0.001), but no significant differences were found in forefoot abduction between the two conditions. The hind foot demonstrated a larger dorsiflexion in the horizontal plane (16.59∘± 1.69∘ VS 12.08∘± 0.9∘; P< 0.001), greater internal rotation (16.72∘± 0.48∘ VS 7.97∘± 0.55∘; P< 0.001), and decreased peak hind foot extension rotation (-5.49∘± 0.69∘ VS -10.73∘± 0.42∘; P= 0.001). These findings complement existing kinematic evidence that wearing high heels can lead to foot deformities and injuries.

Changes in lower limb muscle synchronisation during walking on high-heeled shoes

The goal of this research was to investigate the effect of wearing high-heeled shoes (HHS) on lower limb muscle synchronisation during walking, using beta band (15-30 Hz) coherence analysis. Fifteen females with no previous neuromuscular disorders volunteered in this study. Surface electromyography in frequency domain was studied from rectus femoris (RF), vastus lateralis (VL), vastus medialis (VM) and semitendinosus (ST) muscles during walking by subjects wearing HHS of three different heel heights (low - 4 cm, medium - 6 cm and high - 10 cm). Average coherence values were calculated for RF-VL, RF-VM and RF-ST muscles in beta band to analyse muscle pair synchronisation. In this study, significant increase in beta band coherence was found in all three muscle pairs during walking on HHS of different heel heights (p<0.05). Increased beta band coherence obtained from this study suggested that walking on HHS demands higher muscle pair synchronisation, to maintain stability around the knee joint.

Walking variations in healthy women wearing high-heeled shoes: Shoe size and heel height effects

BACKGROUND

The use of high heels is widespread in modern society in professional and social contests. Literature showed that wearing high heels can produce injurious effects on several structures from the toes to the pelvis. No studies considered shoe length as an impacting factor on walking with high heels.

RESEARCH QUESTION

The aim of this study is to evaluate walking parameters in young healthy women wearing high heels, considering not only the heel height but also the foot/shoe size.

METHODS

We evaluate spatio-temporal, kinematic and kinetic data, collected using a 8-camera motion capture system, in a sample of 21 healthy women in three different walking conditions: 1) barefoot, 2) wearing 12 cm high heel shoes independently from shoe size, and 3) wearing shoes with heel height based on shoe size, keeping the ankles' plantar flexion angle constant. The main outcome measures were: spatio-temporal parameters, gait harmony measurement, range of motion, flexion and extension maximal values, power and moment of lower limb joints.

RESULTS

Comparing the three walking conditions, the Mixed Anova test, showed significant differences between both high heeled conditions (variable and constant height) and barefoot in spatio-temporal, kinematic and kinetic parameters.

SIGNIFICANCE

Regardless of the shoe size, both heeled conditions presented a similar gait pattern and were responsible for negative effects on walking parameters. Considering our results and the relevance of the heel height, further studies are needed to identify a threshold, over which it is possible to observe that wearing high heels could cause harmful effects, independently from the foot/shoe size.

Inter-gender differences of balance indicators in persons 60-90 years of age

Introduction

Precision of movements responsible for maintaining balance deteriorates with age due to natural involutionary processes, thus prompting a research question whether the values of gender-related stability indicators might differ significantly among the study subjects over 60 years of age.

Methods

The study group comprised 136 seniors (89 women, 47 men; aged 60–90 years). The CQ-Stab 2P 2-platform posturograph was used as the main research device, whereas the Mann–Whitney U-test was used to evaluate the gender-related differences in the average level of variables.

Results

In the open-eye test, significant gender-related differences were observed with regard to the statokinesiogram’s path length in the mediolateral (ML) direction in the subjects aged 60–69 years (p=0.004), mean frequency of center of pressure (COP) displacement and number of COP displacements in the ML direction in the subjects aged 70–79 years (p=0.028, p=0.019), and mean COP displacement in the anteroposterior (AP) direction in the subjects aged 80–90 years (p=0.026). When the subjects were deprived of visual control, gender-related differences were observed with regard to the mean frequency of COP displacement, number of COP displacements in the ML direction in the subjects aged 60–69 years (p=0.045, p=0.049), and the statokinesiogram’s path length in the AP direction in the subjects aged 70–79 years (p=0.015). In the oldest age group, the differences were noted in the statokinesiogram’s path length in the AP direction (p=0.001), a sway area delimited by the COP point (p=0.003), range of AP stability (p<0.001), and range of ML stability (p=0.048).

Conclusion

Gender-related differences affecting postural stability were found in the elderly. Men were characterized by a lower level of postural stability when compared with women. This highlights the need to have the gender-related differences taken into account, when developing various preventive and therapeutic programs specifically aimed at compensating certain involution-dependent deficits.

Changes of gait pattern, muscle activity, and perceived comfort in response to variations of height-elevating insoles in young adults

The purpose of this study was to investigate changes of gait pattern, muscle activity, and perceived comfort in response to variations of height-elevating insoles (HEIs) in young adults. The subjects of this study were 30 young adults who voluntarily consented to participate in this experiment after listening to its purpose and method. They were divided into 3 groups who wore HEIs height (0, 3, and 7 cm). Each group consisted of 10 young adults and wore the HEIs for 4 hr a day. Electromyographic signals were collected from the tibialis anterior, the gastrocnemius, the hamstring, and the right and the left erector spinae (ES) before and after walking with the HEI. Gait pattern was measured before and after walking with the HEI. Perceived comfort was measured after a subject wore the insoles for 4 hr. The activities of ES showed significant differences among the three groups. The activity of the left ES was significantly different between groups 1 (0 cm) and 2 (3 cm) and groups 1 and 3 (7 cm). The activity of the right ES was significantly different between groups 1 and 3. The left stride length and the left step length showed significant differences between groups 1 and 3. Perceived comfort was significantly different among the three groups. As the HEIs increased, the activities of ES were gradually increased and the left step length and stride were decreased. Using of higher HEIs over 4 hr may be occurred excessive activities of the ES, abnormal gait patterns, and perceived discomfort.

Effects of high heeled shoes on gait. A review

BACKGROUND

Walking in high heels (HH) may alter gait in various ways, which may be of importance to designers and physicians.

RESEARCH QUESTION

How does walking in high heels alter gait and how can this be explained from a biomechanical and control point of view.

METHODS

Relevant literature has been collected in which high heeled walking was studied, after which the results were bundled and interpreted in a framework of biomechanics and control.

RESULTS

Major changes were found in the rollover function of the feet, the ankle and knee joints and the lower back, while step length and balance were compromised. An increase in heel height forces the foot in an increased plantar flexion, which in its turn increases knee flexion and lordosis of the lower back. All changes can be related with each other in a plausible pattern of movement and control.

Electromyographic changes in muscles around the ankle and the knee joints in women accustomed to wearing high-heeled or low-heeled shoes

OBJECTIVES

This study aimed to investigate muscle activities in the muscles around the ankle and knee joints in women accustomed to wearing high-heeled or low-heeled shoes.

METHODOLOGY

Forty young women (age: 18-40 years) participated in this comparative clinical study. Twenty of the recruited subjects were accustomed to high-heeled shoes and the other half to low-heeled shoes. Electrical activities of the ankle and knee muscles in both groups with and without wearing their accustomed shoes were studied during walking.

RESULTS

Tibialis anterior and the medial gastrocnemius muscles started contraction earlier in the high-heeled shoe group. The duration of medial gastrocnemius activity and the intensity of proneus longus activity were significantly more in the high-heeled shoe group.

CONCLUSION

Wearing high-heeled shoe for a long time could result in over work of muscles such as medial gastrocnemius and proneus longus by increasing the duration or the intensity of their contractions during walking.

Are hospital emergency department visits due to dog bites associated with ambient temperature? A time-series study in Beijing, China

BACKGROUND

It is well documented that suboptimal ambient temperature is associated with cardiovascular and respiratory diseases. However, no study has examined the relation between temperature and dog bites.

OBJECTIVES

To study the association between ambient temperature and daily hospital emergency department visits due to dog bites (EDVDBs) in Beijing, China; and to explore whether the temperature-EDVDB association varies by sex and age.

METHODS

Daily EDVDBs were collected from a hospital appointed for dog bites in Beijing during 2012-2014. A quasi-Poisson regression with distributed lag non-linear model (DLNM) was employed to estimate the impact of temperature on daily EDVDBs. Stratified analysis was performed to examine the temperature-EDVDB association by sex and age-groups. Sensitivity analysis was performed to check the robustness of the results by adjusting other meteorological variables and air pollutants.

RESULTS

A total of 42,481 EDVDBs were collected, with daily cases ranged from 15 to 71. The association between temperature and EDVDBs was U-shaped, with extreme cold temperature showing a weaker, delayed and shorter effect on the risk of dog bites while the effect of extreme hot temperature being stronger, more immediate and lasting longer. Cold temperature had a greater impact on female whereas male was more sensitive to hot temperature. The temperature-EDVDB association was unapparent in the 15-21years group. The cold effect was only significant in the 0-14years group whereas all age-groups suffered from the similar heat effect except those aged 22-45years. Adjusting other meteorological variables and air pollutants did not change the results.

CONCLUSIONS

The impact of temperature on EDVDBs is U-shaped in Beijing, China which varies by sex and age. The temperature effect is independent from other meteorological variables and air pollutants.

Using Gold-standard Gait Analysis Methods to Assess Experience Effects on Lower-limb Mechanics During Moderate High-heeled Jogging and Running

A limited number of studies have explored lower-limb biomechanics during high-heeled jogging and running, and most studies have failed to clarify the wearing experience of subjects. This protocol describes the differences in lower-limb kinematics and ground reaction force (GRF) between experienced wearers (EW) and inexperienced wearers (IEW) during moderate high-heeled jogging and running. A three-dimensional (3D) motion analysis system with a configured force platform was used to synchronously capture lower-limb joint movements and GRF. 36 young females volunteered to participate in this study and were asked about high-heeled shoe-wearing experience, including frequency, duration, heel types, and heel heights. Eleven who had the experience of 3 to 6 cm heels for a minimum of three days per week (6 h per day) for at least two years and eleven who wore high heels less than twice per month participated. Subjects performed jogging and running at comfortable low and high speeds, respectively, with the right foot completely stepping onto a force platform when passing by along a 10 m walkway. EW and IEW adopted different biomechanical adaptations while jogging and running. IEW exhibited a generally larger range of joint movement, while EW showed a dramatically larger loading rate of GRF during running. Hence, further studies on the lower-limb biomechanics of high-heeled gait should strictly control the wearing experience of the subjects.

Habitual Use of High-Heeled Shoes Affects Isokinetic Soleus Strength More Than Gastrocnemius in Healthy Young Females

BACKGROUND

Habitual use of high-heeled shoes (HHS) has been reported to negatively impact different body structures. However, few studies have investigated its effect on plantarflexor performance. The aim of this study was to investigate the effect of habitual wear of HHS and knee joint position (to isolate the function of the gastrocnemius) on the isokinetic performance of the plantarflexors and ankle joint range of motion (ROM).

METHODS

A high-heel (HH) group included 12 women (25.4 ± 4.8 y) who have been wearing HHS for ≥40 hours/wk and for at least a year. A control group (CTRL) had 12 women (21.3 ± 0.5 y) who have occasionally been wearing HHS for <10 hours/wk. Participants performed isokinetic (60 degrees/s) plantarflexion movements through a range set between 15 degrees dorsiflexion and 30 degrees plantarflexion. Ankle joint ROM and average peak plantarflexion torque and power were recorded in 2 knee joint positions, extension and 90 degrees flexion.

RESULTS

Overall, torque was significantly affected by knee position (P = .04) and habitual use of HHS (P < .001), whereas power was impacted by knee position only (P < .001). Within each group, flexing the knee reduced isokinetic measurements. However, the reduction was greater for the HH group (torque: 54 Nm, power: 35.6 W) compared with the CTRL group (torque: 42 Nm, power: 32.5 W). Ankle joint ROM was significantly different between groups in knee flexion only.

CONCLUSION

Flexing the knee limited the plantarflexor muscular performance and the limitation was more significant in habitual users of HHS compared to nonusers. Thus, it is concluded that habitual use of HHS impacts the contractile properties of soleus more than gastrocnemius.

CLINICAL RELEVANCE

The soleus is important for walking and anterior cruciate ligament protection. Thus, HHS users could be susceptible to injury and may need longer and more intensive posttraumatic rehabilitation. Therefore, clinicians should consider knee position when examining the plantarflexors of habitual HHS users.

Effects of duration of wearing high-heeled shoes on plantar pressure

In the present study we investigated the effects of different durations of using high-heeled shoes on plantar pressure and gait. A questionnaire survey and dynamic plantar pressure measurements were performed in 20 control females and 117 females who had worn high-heeled shoes for a long time. According to the duration of using high-heeled shoes (as specified in the questionnaire), subjects were divided into a control group and five groups with different durations of use (i.e. <2years, 2-5years, 6-10years, 11-20years and >20years). Parameters, including peak pressure, impulse and pressure duration, in different plantar regions were measured with the Footscan pressure plate. The 2-5years group had smaller midfoot contact areas for both feet and higher subtalar joint mobility, while the 6-10years group had larger midfoot contact areas for both feet and prolonged foot flat phase during gait. The peak pressure and impulse under the second and fourth metatarsus were increased with the prolonged wearing of high-heeled shoes, and the pressure and impulse under the midfoot were substantially reduced in the 2-5years group. The findings suggest that long-term use of high-heeled shoes can induce changes in arch morphology: the longitudinal arch tends to be elevated within 2-5years; the longitudinal arch tends to be flattened within 6-10years; and the forefoot latitudinal arch tends to collapse in more than 20years.

Lower limb mechanics during moderate high-heel jogging and running in different experienced wearers

The aim of this study is to investigate the differences in lower limb kinematics and kinetics between experienced (EW) and inexperienced (IEW) moderate high-heel wearers during jogging and running. Eleven experienced female wearers of moderate high-heel shoes and eleven matched controls participated in jogging and running tests. A Vicon motion analysis system was used to capture kinematic data and a Kistler force platform was used to collect ground reaction force (GRF). There were no significant differences in jogging and running speed respectively. Compared with IEW, EW adopted larger stride length (SL) with lower stride frequency (SF) at each corresponding speed. During running, EW enlarged SL significantly while IEW increased both SL and SF significantly. Kinematic data showed that IEW had generally larger joint range of motion (ROM) and peak angles during stance phase. Speed effect was not obvious within IEW. EW exhibited a significantly increased maximal vertical GRF (Fz2) and vertical average loading rate (VALR) during running, which was potentially caused by overlong stride. These suggest that both EW and IEW are at high risk of joint injuries when running on moderate high heels. For wearers who have to do some running on moderate high heels, it is crucial to control joint stability and balance SL and SF consciously.

The impact of high-heeled shoes on ankle complex during walking in young women-In vivo kinematic study based on 3D to 2D registration technique

OBJECTIVE

To explore the accurate in vivo kinematic changes in the ankle complex when wearing low- and high-heel shoes (LHS and HHS, respectively).

MATERIALS AND METHODS

Twelve young women were tested unilaterally. Three-dimensional models of the tibia, talus, and calcaneus were first created based on CT scan results. The subjects walked at a self-controlled speed in barefoot, LHS (4cm), and HHS (10cm) conditions. A fluoroscopy system captured the lateral fluoroscopic images of the ankle complex. The images of seven key positions in the stance phase were selected, and 3D to 2D bone model registrations were performed to determine the joint positions. The mean of 6 degree of freedom (DOF) range of motions (ROM), joint positions, and angular displacements of the ankle complex during the gait were then obtained.

RESULTS

For the talocrural joint, the rotational ROMs of the subjects either in LHS or HHS condition displayed no significant difference from those in barefoot condition. For the subtalar joint, all the rotational ROMs in the HHS condition and the internal/external rotations in the LHS condition significantly decreased compared with those in the barefoot condition. The talocrural joint was positioned significantly more plantarflexed, inverted, internally rotated, and posteriorly seated in all seven poses in HHS condition, compared with those in barefoot condition.

CONCLUSION

HHS mainly affected the rotational motion of the ankle complex during walking. The talocrural joint position was abnormal, and the subtalar joint ROM decreased during the gait in HHS condition. Only a few kinematic changes occurred in LHS condition relative to the barefoot condition.

Effects of high heeled shoes wearing experience and heel height on human standing balance and functional mobility

This study aimed to examine the effects of high heeled shoes (HHS) wearing experience and heel height on human standing balance and functional mobility. Thirty young and healthy females (ten experienced and twenty inexperienced HHS wearers) participated in a series of balance tests when they wore shoes of four different heel heights: 1 cm (flat), 4 cm (low), 7 cm (medium) and 10 cm (high). Experimental results show that regardless of the wearing experience, the heel elevation induces more effort from lower limb muscles (particularly calf muscles) and results in worse functional mobility starting at 7 cm heel height. While the heel height increased to 10 cm, the standing balance also becomes worse. Experienced HHS wearers do not show significantly better overall performance on standing balance and functional mobility than inexperienced controls, even though they have better directional control (76.8% vs. 74.4%) and larger maximum excursion (93.3% vs. 89.7%). To maintain standing balance, experienced wearers exert less effort on tibialis anterior, vastus lateralis and erector spinae muscles at the cost of more intensive effort from gastrocnemius medialis muscle.

PRACTITIONER SUMMARY

Many women wear high heeled shoes (HHS) to increase female attractiveness. This study shows that HHS induce more muscular effort and worse human standing balance and functional mobility, especially when heel height reaches 10 cm. HHS wearing experience only provides certain advantages to wearers on limits of stability in terms of larger maximum excursion and better directional control.

Barefoot vs common footwear: A systematic review of the kinematic, kinetic and muscle activity differences during walking

Habitual footwear use has been reported to influence foot structure with an acute exposure being shown to alter foot position and mechanics. The foot is highly specialised thus these changes in structure/position could influence functionality. This review aims to investigate the effect of footwear on gait, specifically focussing on studies that have assessed kinematics, kinetics and muscle activity between walking barefoot and in common footwear. In line with PRISMA and published guidelines, a literature search was completed across six databases comprising Medline, EMBASE, Scopus, AMED, Cochrane Library and Web of Science. Fifteen of 466 articles met the predetermined inclusion criteria and were included in the review. All articles were assessed for methodological quality using a modified assessment tool based on the STROBE statement for reporting observational studies and the CASP appraisal tool. Walking barefoot enables increased forefoot spreading under load and habitual barefoot walkers have anatomically wider feet. Spatial-temporal differences including, reduced step/stride length and increased cadence, are observed when barefoot. Flatter foot placement, increased knee flexion and a reduced peak vertical ground reaction force at initial contact are also reported. Habitual barefoot walkers exhibit lower peak plantar pressures and pressure impulses, whereas peak plantar pressures are increased in the habitually shod wearer walking barefoot. Footwear particularly affects the kinematics and kinetics of gait acutely and chronically. Little research has been completed in older age populations (50+ years) and thus further research is required to better understand the effect of footwear on walking across the lifespan.

Epidemiology of High-Heel Shoe Injuries in U.S. Women: 2002 to 2012

The purpose of the present study was to investigate the epidemiology of high-heel-related injuries among a nationally representative population of women in the United States and to analyze the demographic differences within this group. The data used in the present study were collected from the Consumer Product Safety Commission's National Electronic Injury Surveillance System. A total of 3294 injuries, representing an estimated 123,355 high-heel-related injuries, were treated in emergency departments within the United States from 2002 to 2012. The overall rate of high-heel-related injuries for the study was 7.32 per 100,000 females (95% confidence interval 7.08 to 7.56). The injury rate was greatest for young adult females, with the greatest rates observed for those aged 20 to 29 years (18.38 per 100,000 females) and those aged 30 to 39 years (11.07 per 100,000 females). The results from the present study suggest that high-heel-related injuries have nearly doubled during the 11-year period from 2002 to 2012. Injuries from high heels are differential by body region, with most injuries occurring as sprains and strains to the foot and ankle. Although high heels might be stylish, from a health standpoint, it could be worthwhile for females and those interested in wearing high heels to understand the risks of wearing high-heeled shoes and the potential harm that precarious activities in high-heeled shoes can cause. The results of the present study can be used in the development of a prospective cohort study to investigate the risk of injury from high-heeled shoes, accounting for the exposure time and studying differences in demographics (e.g., age and race).

On high heels and short muscles: a multiscale model for sarcomere loss in the gastrocnemius muscle

High heels are a major source of chronic lower limb pain. Yet, more than one third of all women compromise health for looks and wear high heels on a daily basis. Changing from flat footwear to high heels induces chronic muscle shortening associated with discomfort, fatigue, reduced shock absorption, and increased injury risk. However, the long-term effects of high-heeled footwear on the musculoskeletal kinematics of the lower extremities remain poorly understood. Here we create a multiscale computational model for chronic muscle adaptation to characterize the acute and chronic effects of global muscle shortening on local sarcomere lengths. We perform a case study of a healthy female subject and show that raising the heel by 13cm shortens the gastrocnemius muscle by 5% while the Achilles tendon remains virtually unaffected. Our computational simulation indicates that muscle shortening displays significant regional variations with extreme values of 22% in the central gastrocnemius. Our model suggests that the muscle gradually adjusts to its new functional length by a chronic loss of sarcomeres in series. Sarcomere loss varies significantly across the muscle with an average loss of 9%, virtually no loss at the proximal and distal ends, and a maximum loss of 39% in the central region. These changes reposition the remaining sarcomeres back into their optimal operating regime. Computational modeling of chronic muscle shortening provides a valuable tool to shape our understanding of the underlying mechanisms of muscle adaptation. Our study could open new avenues in orthopedic surgery and enhance treatment for patients with muscle contracture caused by other conditions than high heel wear such as paralysis, muscular atrophy, and muscular dystrophy.

Effects of long-term wearing of high-heeled shoes on the control of the body's center of mass motion in relation to the center of pressure during walking

High-heeled shoes are associated with instability and falling, leading to injuries such as fracture and ankle sprain. This study investigated the effects of habitual wearing of high-heeled shoes on the body's center of mass (COM) motion relative to the center of pressure (COP) during gait. Fifteen female experienced wearers and 15 matched controls walked with high-heeled shoes (7.3cm) while kinematic and ground reaction force data were measured and used to calculate temporal-distance parameters, joint moments, COM-COP inclination angles (IA) and the rate of IA changes (RCIA). Compared with inexperienced wearers, experienced subjects showed significantly reduced frontal IA with increased ankle pronator moments during single-limb support (p<0.05). During double-limb support (DLS), they showed significantly increased magnitudes of the frontal RCIA at toe-off and contralateral heel-strike, and reduced DLS time (p<0.05) but unaltered mean RCIA over DLS. In the sagittal plane experienced wearers showed significantly increased mean RCIA (p<0.05) and significant differences in the RCIA at toe-off and contralateral heel-strike (p<0.05). Significantly increased hip flexor moments and knee extensor moments at toe-off (p<0.05) were needed for forward motion of the trailing limb. The current results identified the change in the balance control in females after long-term use of high-heeled shoes, providing a basis for future design of strategies to minimize the risk of falling during high-heeled gait.