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Changes in Ankle Range of Motion and Muscle Strength in Habitual Wearers of High-Heeled Shoes

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Although cross-sectional biomechanical studies have reported that wearing high-heeled shoes can change the musculoskeletal system of the lower extremities, the long-term effects of wearing such shoes on the ankle remain unknown. The aim of this study was to reveal changes in ankle range of motion and muscle strength in habitual wearers of high-heeled shoes and to provide information for clinicians undertaking functional evaluations of the ankles of such patients. Habitual wearers of high-heeled shoes (n = 10; age, 23.9 ± 2.7 years) and wearers of flat shoes (n = 10; age, 23.8 ± 2.1 years) were selectively recruited, and the range of motion, maximal voluntary isometric force, and concentric contraction power of their ankles were measured. Wearers of high-heeled shoes showed increased ankle range of motion on plantarflexion at 25 degrees and inversion at 10 degrees compared to flat shoe wearers (P < .05) but decreased dorsiflexion (about 17 degrees) and eversion (13 degrees; P < .05). Concentric contraction power in ankle eversion was also 2 times higher in wearers of high-heeled shoes (P < .05). These subjects had functional deformity of the ankle in a supinated direction and increased eversion power. We cautiously recommend that habitual wearers of high-heeled shoes (those who walk in such shoes for more than 5 hours more than 6 times a week) undertake intensive ankle stretching exercises in the direction of dorsiflexion as well as eversion.
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Foot & Ankle International
34(3) 414 –419
© The Author(s) 2013
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DOI: 10.1177/1071100712468562
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Various studies have warned women that wearing high-
heeled shoes (HHS) for a long time can cause musculoskel-
etal changes in the kinematics and kinetics of the lower
extremities and trunk.2,24 Kinematic changes that occur during
walking, such as increased ankle plantarflexion and hyperex-
tension of the metatarsophalangeal joint, are caused by wear-
ing HHS.7,12 In particular, the risk of metatarsalgia caused by
increased plantar pressure at the metatarsal head is increased
with frequent wearing of HHS.1,15,18,25 Kinetic changes also
occur; that is, plantar pressure moves inward,20,22 and the
center of mass moves forward.14
The kinematic and kinetic changes caused by HHS might
induce deformities of the ankle and metatarsophalangeal
joints. However, most studies performed to determine the
musculoskeletal changes induced by HHS have included a
period during which HHS were not worn. Therefore, it is
necessary to undertake a survey to measure the changes that
accompany the actual frequency of wearing HHS.
Previous studies have shown that habitual wearers of
HHS have limited full extension of the knee during walk-
ing,23 increased fatigue of the peroneus muscle,11 and
increased Achilles tendon stiffness.6 However, the long-
term effects of HHS on ankle range of motion (ROM) and
muscle strength remain to be discovered.
The purpose of this study was to compare the ankle
ROM and muscle strength of habitual wearers of HHS and
flat shoes (FS) and to identify characteristics of the ankles
of habitual wearers of HHS. When women wear HHS, their
ankle joints are placed in a more plantarflexed position and
require more stability. We postulate that frequent wearing of
HHS for a long time increases the maximal range of ankle
plantarflexion and inversion and eversion strength.
Methods
Participants
A total of 20 women (age range, 21-29 years) participated
in our study. Participants with dysfunction of the neural or
musculoskeletal system or pain were excluded. All completed
468562FA
IXXX10.1177/1071100712468562Foot & Ankle InternationalKim et al
2013
1Korea University, Seoul, Republic of Korea
2Gachon University of Medicine and Science, Republic of Korea
Corresponding Author:
BumChul Yoon, Korea University, Primary Work, Physical Therapy,
San1, Jeongneung 3-dong, Sungbuk-gu, Seoul, 136-703, Republic of Korea
Email: yoonbc@korea.ac.kr
Changes in Ankle Range of Motion
and Muscle Strength in Habitual
Wearers of High-Heeled Shoes
Yushin Kim, PT, MHSc1, Jong-Min Lim, PT, BSc2, and BumChul Yoon, PT, OT, PhD1
Abstract
Background: Although cross-sectional biomechanical studies have reported that wearing high-heeled shoes can change
the musculoskeletal system of the lower extremities, the long-term effects of wearing such shoes on the ankle remain
unknown. The aim of this study was to reveal changes in ankle range of motion and muscle strength in habitual wearers of
high-heeled shoes and to provide information for clinicians undertaking functional evaluations of the ankles of such patients.
Methods: Habitual wearers of high-heeled shoes (n = 10; age, 23.9 ± 2.7 years) and wearers of flat shoes (n = 10; age,
23.8 ± 2.1 years) were selectively recruited, and the range of motion, maximal voluntary isometric force, and concentric
contraction power of their ankles were measured.
Results: Wearers of high-heeled shoes showed increased ankle range of motion on plantarflexion at 25 degrees and
inversion at 10 degrees compared to flat shoe wearers (P < .05) but decreased dorsiflexion (about 17 degrees) and eversion
(13 degrees; P < .05). Concentric contraction power in ankle eversion was also 2 times higher in wearers of high-heeled
shoes (P < .05).
Conclusions: These subjects had functional deformity of the ankle in a supinated direction and increased eversion power.
Clinical Relevance: We cautiously recommend that habitual wearers of high-heeled shoes (those who walk in such
shoes for more than 5 hours more than 6 times a week) undertake intensive ankle stretching exercises in the direction of
dorsiflexion as well as eversion.
Keywords: ankle, muscle strength, muscle power, physical examination, range of motion, high-heeled shoes
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Kim et al 415
a questionnaire with demographic information, medical
history, and the duration of the period over which they wore
HHS over the preceding 6 months. The participants were
divided into 2 groups based on the criteria outlined in
another study7: an HHS group and a FS group. The HHS
group included 10 women who had worn HHS at least
3 days a week over the past 6 months. The FS group
included 10 women who had worn HHS less than 3 days a
week over the past 6 months. The 2 groups were not sig-
nificantly different in terms of age, height, weight, foot
length, foot width, or total period of wearing HHS.
Furthermore, none had regularly participated in any sports,
strength training, or stretching exercises for the past
6 months. Two subjects were excluded from the study
because they had a low likelihood of wearing HHS over the
past 6 months, although they had often worn HHS for more
than 3 days a week for the previous 1 month. A total of
22 participants were recruited in this study. The Ethics
Committee of Korea University approved this study. All
participants provided their informed consent, and their
identities were coded to protect their privacy.
Measurement of ROM
To examine changes in maximum ankle ROM caused by
HHS, active and passive ROM was measured using an incli-
nometer (Angle Finder AF200M, Dasco Pro Inc, Rockford,
IL). Maximal angular ranges of inversion, eversion, plan-
tarflexion, dorsiflexion with the knee at 90 degrees of flex-
ion (DF-KF), and dorsiflexion with the knee fully extended
(DF-KE) were measured. To measure the ROM of inver-
sion and eversion, the subjects were seated with their feet
off the floor to ensure that the anterior border of the tibia
was vertical and to prevent hip rotation. After fixation, the
angles of the movement of the metatarsal head in the fron-
tal plane were checked. To measure the ROM of plan-
tarflexion and dorsiflexion, subjects were asked to place
their ankles over the edge of a table while lying in a supine
position. Then, the maximal movement angle of the fifth
metatarsal bone was used to determine the ankle ROM on
the sagittal plane relative to the vertical. To examine the
effects on the soleus and gastrocnemius muscles, dorsiflex-
ion was checked with the knee at 90 degrees flexion and
fully extended. To measure DF-KF, the subject lay in a
supine position with hip and knee at 90 degrees flexion
with the tibia fixed in place horizontally. The angle of ankle
maximal dorsiflexion from the vertical was then measured.
All measurements were taken 3 times.
Measurement of Muscle Strength
Ankle muscle strength was measured using a multimodal
dynamometer (Primus RS, BTE Technologies Inc., Baltimore,
MD). To measure the maximal voluntary isometric force
(MVIF) in 4 directions (inversion, eversion, plantarflexion,
and dorsiflexion) of both ankles, an axis of dynamometer
was fixed in place. Concentric contraction power at the 25%
and 75% MVIF levels was measured for both ankles in the
same MVIF posture, and subjects were instructed to use
maximal effort to ensure concentrated speed as well as
force. Measurement postures were determined in the plan-
tarflexion, dorsiflexion, inversion, and eversion directions.
To measure dorsiflexion and plantarflexion, the subject lay in
a supine position with the pelvis and tibia fixed in position
up on a table (see Figure 1). Strength of ankle eversion and
inversion was then measured in a sitting position by fixing
the thigh in place to prevent movement of the hip joint (see
Figure 2). All measurements were repeated 3 times.
Statistical Analysis
Our purpose was to compare the ROM, MVIF, and concen-
tric contraction power at 25% and 75% MVIF between the
HHS and FS groups. We used an independent t test to com-
pare demographic characteristics and the period of wearing
HHS between groups. Levene’s test for equality of vari-
ances was used in relation to the underlying assumptions of
parametric statistics. The reproducibility of trials was tested
by intraclass correlation coefficients. Data from the
2 groups included the average of 3 trials for the left and
right ankles and were compared by repeated measures
analysis of variance in SPSS 12.0. Statistical significance
was accepted for P values less than .05.
Figure 1. The position used for the ankle strength
measurements (maximal voluntary isometric force and
concentric contraction power) of dorsiflexion and plantarflexion.
The axis of a multimodal dynamometer was located at the lateral
malleolus, and the distal part of the tibia was fixed in position.
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416 Foot & Ankle International 34(3)
Results
No significant differences between the HHS and FS groups
in mean age, height, weight, foot length, foot width, or
period of wearing HHS were observed. However, a signifi-
cant difference was observed in the frequency of wearing
HHS and walking while wearing HHS for a week (Table 1).
Moreover, the maximum ROM differed between the HHS
and FS groups. ROM measures were dichotomized as
active and passive ROM. Measurement of active ROM was
chiefly performed in the clinical field because most of the
tasks performed during daily life require active ROM.4
Passive ROM was measured to confirm the passive visco-
elastic properties of the involved muscles, pain, and neural
inhibition.27
Ankle ROM
The maximum active and passive ROM of plantarflexion
and inversion was approximately 25 degrees and 10
degrees higher, respectively, in the HHS group compared
with the FS group (P < .05). In contrast, maximum DF-KE
and eversion were 16 degrees and 9 to 4 degrees higher in
the FS group compared with the HHS group (P < .05). In
DF-KF, only passive ROM was significantly decreased by
6 degrees in the HHS group (P < .05). The active and pas-
sive ROM values are shown in Table 2. Based on 3 ROM
measurements, the minimum intraclass correlation coeffi-
cient value was 0.886.
Ankle Strength
Ankle strength was assessed on the basis of MVIF and
concentric contraction power. The MVIF in eversion was
higher in the HHS group than the FS group; however, there
was no statistical difference between the 2 groups in all
directions (P > .05). The concentric contraction power was
measured at 25% and 75% of MVIF in both the FS and
HHS groups. Except for eversion, no significant difference
in concentric power was observed between the 2 groups.
The HHS group had higher eversion power (range, around
2-3 W) than the FS group (P < .05) at both 25% and 75%
of MVIF. The mean values of ankle muscle strength are
shown in Table 3. Based on 3 trials, the intraclass correla-
tion coefficient for MVIF, with concentric contraction
power at 25% and 75% of MVIF, was over 0.871.
Discussion
To understand clinically the musculoskeletal effects of
wearing HHS, orthopaedic examination of habitual high-
heeled shoe wearers is important. The purpose of this study
was to compare ankle ROM and muscle strength between
habitual wearers of HHS and FS. We found that the physi-
cal ability of the ankles of wearers of HHS was signifi-
cantly different from that of the wearers of FS in terms of
kinematics and kinetics.
Regarding kinematic changes, the maximum ROM of
plantarflexion and inversion was higher in the HHS group
compared with the FS group; however, DF-KE and eversion
were lower. This indicates that the range of ankle joint
mobility in the HHS group was shifted to a supinated posi-
tion. These results lead to the speculation that tissues around
the ankle become lax on the anterolateral side and stiff on
the posteromedial side—that is, an elongated anterior talo-
fibular ligament and a stiff deltoid ligament and Achilles
tendon. We considered that changes in ankle ROM related
to the supinated position were caused by kinematic charac-
teristics during walking with HHS. Other studies have
reported increased maximum peak angles of plantarflexion
and inversion in the ankle during walking with HHS; how-
ever, their experimental data compared maximum peak
angles of the ankle in HHS and FS and were inconsis-
tent.7,17,29,30 Thus, it is possible that the gait pattern when
wearing HHS affects supinated deformation of the ankle
ROM in wearers of HHS.
In particular, the ankle plantarflexed position in HHS
would reduce the length of the gastrocnemius muscle relative
to the other calf muscles. We dichotomized dorsiflexion
ROM in the knee at full extension and at 90 degrees of flex-
ion because examinations of ankle dorsiflexion at different
knee positions are useful for discriminating posterior ankle
structure shortening between monoarticular and biarticular
Figure 2. The position used for the ankle strength
measurements (maximal voluntary isometric force and
concentric contraction power and concentric contraction
power) of inversion and eversion. The lever arm of a multimodal
dynamometer and the body of the femur were lined up, and the
distal part of the femur was fixed in position.
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Kim et al 417
Table 2. Comparisons of Active and Passive Range of Motion, in Degreesa
Active Passive
Direction FS HHS FS HHS
DF-KE 16.1 ± 9.4b0.1 ± 8.4 21.9 ± 9.6b4.0 ± 9.5
DF-KF 26.4 ± 6.2 24.4 ± 6.7 35.4 ± 6.3b29.5 ± 8.3
Plantarflexion 80.7 ± 16.9 100.8 ± 13.4c88.6 ± 22.7 106.8 ± 16.2c
Inversion 42.7 ± 9.8 53.0 ± 16.3c50.0 ± 8.9 60.5 ± 17.2c
Eversion 32.9 ± 12.9b21.2 ± 10.5 38.9 ± 13.4b24.6 ± 8.9
Abbreviations: FS, flat shoes group; HHS, high-heeled shoes group; DF-KE, dorsiflexion in knee full extension; DF-KF, dorsiflexion in knee 90 degrees of
flexion.
aMean ± standard deviation.
bAngle of maximum range of motion is significantly higher than HHS (P < .05).
cAngle of maximum range of motion is significantly higher than FS (P < .05).
Table 3. Comparisons of Ankle Isometric Force and Concentric Powera
Isometric Force (N)
Concentric Power
at 25% Load Level (W)
Concentric Power
at 75% Load Level (W)
Direction FS HHS FS HHS FS HHS
Dorsiflexion 28.4 ± 6.2 25.1 ± 8.3 5.6 ± 3.7 5.1 ± 2.1 9.2 ± 3.6 10.0 ± 4.4
Plantarflexion 27.1 ± 9.7 24.0 ± 9.3 6.4 ± 3.6 6.1 ± 3.7 13.5 ± 7.4 11.4 ± 9.5
Inversion 22.9 ± 11.2 26.6 ± 15.8 5.9 ± 3.3 7.7 ± 4.8 11.1 ± 8.8 13.7 ± 10.0
Eversion 13.8 ± 7.8 19.2 ± 9.2 2.9 ± 2.7 5.0 ± 4.0b5.1 ± 3.4 8.1 ± 5.2b
Abbreviations: FS, flat shoes group; HHS, high-heeled shoes group.
aMean ± standard deviation.
bConcentric power is significantly higher than HHS (P < .05).
Table 1. Anthropometric Characteristics of Participantsa
FS, n = 10 HHS, n = 10 t P
Mean age, y 23.8 ± 2.1 23.9 ± 2.7 –0.092 .928
Height, cm 165.0 ± 4.8 162.8 ± 4.6 1.071 .298
Weight, kg 54.2 ± 4.6 54.0 ± 4.8 0.096 .925
Foot length, mm 237.2 ± 11.5 239.7 ± 5.4 –0.592 .562
Foot width, mm 8.6 ± 0.6 8.8 ± 0.3 –0.578 .576
Total wearing period, yb3.8 ± 1.7 5.6 ± 1.2 –0.438 .667
Wearings for a week, nc1.1 ± 0.8 5.5 ± 1.3 –7.782 <.001
Wearing periods for a week, hd2.3 ± 1.7 4.6 ± 0.9 –4.347 <.001
Preferred heel height 5.6 ± 1.4 7.6 ± 2.3 –1.993 .062
Abbreviations: FS, flat shoes group; HHS, high-heeled shoes group.
aMean ± standard deviation.
bWearing period of the high-heeled shoes in participants’ lifetime.
cFrequency of wearing the high-heeled shoes for a week.
dWalking period with wearing the shoes per week.
muscles.19 The maximum ROM of DF-KE was about
16 degrees lower in the HHS group compared with the FS
group, whereas DF-KF was not different or was only slightly
different. This indicates that the gastrocnemius muscle fascia
of the HHS group was shorter than the other ankle structures,
such as the soleus muscle and the posterior joint capsule.
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418 Foot & Ankle International 34(3)
The supinated metamorphosis of the ankle in the HHS
group would lead to functional changes in the musculoskel-
etal system; that is, it would disturb efficient shock absorp-
tion of the deltoid and spring ligament7 and increase the risk
of anterior talofibular ligament sprains.21 In addition, lim-
ited ankle dorsiflexion ROM is associated with poor calf
muscle pump function in limbs with chronic venous insuf-
ficiency19 and could contribute to increased gait deviations,
such as decreased step length and walking speed.8 Thus, we
were able to establish that kinematic changes induced by
wearing HHS have a negative influence on the ankle and
that regular ankle stretching in the direction of dorsiflexion,
with the knee extended, and at eversion is essential for
habitual wearers of HHS.
We also found that the HHS group had a significantly
higher concentric contraction power in eversion than the FS
group. Muscle power is the ability of a muscle to produce
force rapidly, is defined as the product of force and time,
and is generated during activities that involve movement.28
We first considered that increased muscle power of eversion
would be induced as an adaption to mediolateral instability
induced by a narrow heel. A previous study also reported
that peroneus muscle activity was increased during walking
with heeled shoes owing to a decreased base of support.30
The enhanced eversion power observed in the HHS group
indicates that ankle instability while wearing HHS can
induce a rapidly generated force affecting the peroneus
muscle and that this is important for preventing ankle
sprains.3,5,16 Second, increased eversion power results from
shifting the center of the body mass laterally when women
walk in HHS.11 That is, the medial longitudinal arch and the
spring ligament complex are key structures for shock
absorption generally.26,30 During the stance phase of walk-
ing wearing HHS, however, the center of gravity shifts lat-
erally with increased hip adduction. The external moment
arm of the ankle axis is increased, and the peroneus muscle
requires more power to maintain balance. This process
emphasizes the role of the peroneus muscle as a shock
absorber. Thus, the increased mediolateral instability and
the lateral transfer of the center of gravity during walking in
HHS act as the main effectors increasing the concentric
power of ankle eversion.
Our results show that habitual wearers of HHS have to
increase dorsiflexion and eversion ROM. Thus far, several
studies have reported the effect of stretching exercises on
the calf muscles to increase the dorsiflexion ROM of nor-
mal subjects.9,10,13,31,32 Of these, a passive stretching exer-
cise with programmed long, frequent stretching times (more
than 150 seconds per day, 5 days per week for 6 to 8 weeks)
with a short resting period had a positive effect on increas-
ing ankle ROM.9,10,13 For habitual wearers of HHS, more
intensive stretching exercises are necessary. In addition, our
study suggests that the stretching exercises should be per-
formed in the direction of not only dorsiflexion but also
eversion. Further studies are required to determine whether
the intensity of the outlined stretching program is effective
for habitual wearers of HHS.
In conclusion, this study found that habitual wearers of
HHS have a significantly altered musculoskeletal system in
the ankle, resulting in supinated ROM and increased ever-
sion power. Moreover, ankle adaptations to maintain bal-
ance from a narrow base of support when wearing HHS
evoke kinematic and kinetic changes. However, the ankle
adaptations are known to have a clinically negative impact
by increasing the risk of inversion sprains,21 poor calf mus-
cle pumping,19 and unstable gait.8 Therefore, we recom-
mend that clinicians check the frequency of a patient’s
wearing of HHS and that they understand the physical char-
acteristics of the ankles of habitual wearers of HHS when
undertaking functional evaluations.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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... Kim et al. found that ankle plantar flexion ROM was 25º higher in females wearing HHS than in females not wearing HHS, whereas foot inversion ROM mean value was 10º lower in females wearing HHS than in females not wearing HHS. Also, eversion ROM was 10º higher in females not wearing HHS than in females wearing HHS [24]. Dorsiflexion ROM was 17º higher in females not wearing HHS than in females wearing HHS [24]. ...
... Also, eversion ROM was 10º higher in females not wearing HHS than in females wearing HHS [24]. Dorsiflexion ROM was 17º higher in females not wearing HHS than in females wearing HHS [24]. In this study, wearers of high-heeled shoes showed increased ankle range of motion on plantarflexion at 5.85 (right) and 5.89 (left) degrees (p < 0.001) and inversion at 0.53 (right) and 0.59 (left) degrees (p > 0.05) and eversion 0.26 (right) and 0.19 (left) degrees (p > 0.05) compared to flat shoe wearers but decreased on dorsiflexion at 1.81 (right) and 1.36 (left) degrees (P < 0.001). ...
... In this study, wearers of high-heeled shoes showed increased ankle range of motion on plantarflexion at 5.85 (right) and 5.89 (left) degrees (p < 0.001) and inversion at 0.53 (right) and 0.59 (left) degrees (p > 0.05) and eversion 0.26 (right) and 0.19 (left) degrees (p > 0.05) compared to flat shoe wearers but decreased on dorsiflexion at 1.81 (right) and 1.36 (left) degrees (P < 0.001). Moreover, Kim et al. [24] reported that the plantar flexion was 20º more in females wearing HHS than in females not wearing HHS, whereas these differences were less in our study. Our dorsiflexion result is closer to that of the report from Hallaçeli et al. [13], whereas our eversion ROM values are lower than Hallaçeli et al.'s findings [13] and similar to the AMA [33]. ...
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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.
... 5,6 Numerous researches have warned females who wear HHS for prolong period of time that HHS can result into the development of changes in musculoskeletal system within the kinetics and kinematics of lower extremity and trunk. 7 It was found that HH may lead to foot-pain and deformities 2 and foot pain is aggravated by walking, prolong standing and stair climbing. 8 Many studies shows that high heels are responsible for hallux valgus, deformity, plantar calluses and reduced venous function in lower extremity. ...
... test-retest reliability for concentric power of the ankle, hip force, isotonic functional tasks and static isotonic upper limb strength testing. [24][25][26] The factory calibrated the PrimusRS prior to delivery and researchers calibrated the PrimusRS prior to each testing session to ensure accurate measurment. 22 ...
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Background: Inclusion of resistance training as part of a general fitness program to improve health, and lower risk of disease and injury is well established. Two common options to improve strength are elastic bands and weights. Comparison between elastic bands (as the sole resistance) to isotonic strengthening for concentric and eccentric strength outcomes following the use of low repetitions/heavy resistance has not been reported. Hypothesis/purpose: The purpose was to examine the effects of a four-week isotonic low repetitions/heavy resistance strengthening program compared to a low repetitions/heavy resistance elastic band strengthening program on shoulder external rotation, hip abduction, and elbow flexion concentric and eccentric isokinetic force production in college aged untrained females. Study design: Randomized Trial. Methods: Twenty healthy females performed pre-and-post isokinetic (60 degrees/second) concentric/eccentric testing of the elbow flexors, shoulder external rotators, and hip abductors. Participants were randomly assigned to a four-week independent low repetitions/heavy resistance strengthening program performed with either elastic bands or isotonic exercises. Results: A significant (p < 0.05) effect of time was found for eccentric elbow flexor and concentric and eccentric hip abduction force production in the elastic band group with post-test values greater than pre-test values. A significant (p < 0.05) effect of time was found for elbow flexor concentric and eccentric force production in the isotonic group with post-test values greater then pre-test values. No significant (p>0.05) effect of time was found for shoulder external rotator concentric and eccentric forces for both groups, the isotonic group's hip abduction concentric and eccentric force production and elastic band group's elbow flexion concentric force production. No significant effect of intervention (p >0.05) on concentric or eccentric elbow flexors, shoulder external rotators, or hip abductors force production was found, with pre-test and post-test values being similar between groups. Conclusion: Health care practitioners and coaches can consider the prescription of a heavy resistance training program with elastic bands or isotonic exercises for an independent exercise program and expect similar concentric and eccentric muscle force changes. Level of evidence: Level 2b.
... Previous studies on either high-heeled shoes or load carriage indicated that both factors alter the gait patterns and raise the potential to generate joint pain. 2,3 Wearing high-heeled shoes affects temporospatial parameters, 4,5 such as increased double-leg stance time and decreased walking velocity, step length, and width. These changes in gait are similar to those observed in older populations or patients with musculoskeletal disorders. ...
Article
Background Wearing high-heeled shoes and carrying asymmetrical loads are common in ladies. However, knowledge of the effects of wearing high-heeled shoes on balance and lower-extremity biomechanics in experienced and novice high-heeled shoe wearers is lacking. The study aims to examine the effects of high-heeled shoes and asymmetrical load carrying on joint kinematics and kinetics of the lower extremity during walking as well as balance in experienced and novice high-heeled shoe wearers. Methods Fifteen experienced and 15 novice high-heeled shoes wearers participated in this study. Using a motion analysis system, kinematic and kinetic data were collected while participants walked at their preferred speed in six conditions created from two types of shoes (9-cm high-heeled shoes and flat-heeled shoes) and three weights of symmetrical load (0%, 5%, and 10% of body weight). Stride time and length, step length, double support time, peak joint angles, and joint moments in a sagittal plane were analyzed. Single-leg and tandem-leg stance tests were performed in each condition. Results Compared with experienced high-heeled shoe wearers, novice high-heeled shoe wearers had longer double support time and shorter stride length during 10% of body weight asymmetrical load walking; walked with greater knee flexion angle, smaller knee range of motion, and smaller ankle dorsiflexor moment; and scored lower in the single-leg and tandem-leg stance tests. Conclusions Novice high-heeled shoe wearers need to alter their lower-limb joint angles and moments to adjust to high-heeled shoes to achieve balance during gait while carrying an asymmetrical load.
... To a certain extent, the effect of these extraordinary HH would be expected to be similar to the documented effects of HH, which worsen as the heel height increases. The documented effects are various, structural and morphological [4,5,28,[30][31][32]; such as: posture instability and irreversible postural deviations; increased compression pressure on the lumbar spine and activity of the erector spine muscle, leading to back pain; deformities of the toes and calluses under the metatarsal heads; with a remarkable worsening of overuse injuries and ankles injuries secondary to wearing HH. Furthermore, the frequency of wearing these heals will stiffen and fatigue the muscles (notably the tibialis anterior, lateral gastrocnemius and medial gastrocnemius [33]). ...
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Introduction High heeled shoes have long been worn in society and they are known to cause biomechanical imbalances to not only the foot, but the whole musculoskeletal system. This study aims to show the detailed changes that happen to the shape of the transverse arch of the foot in high heels, using two different inclination degrees. Methods 68 women participated in this study. Two custom-made high heels were made with inclinations of 15 degrees and 30 degrees (cm). A weight-bearing ultrasound was used to assess the coronal view of the transverse arch in standing. ANOVA and Tuckey tests were used to compare the results between 0 degrees, 15 degrees and 30 degrees inclinations. Results The transverse arch height was slightly increased as the heel height increased (0DI-15DI: p = 0.5852 / 15DI-30DI: p = 0.395 / 0DI-30DI: p = 0.0593). The transverse arch length (0DI-15DI: p = 0.0486 / 15DI-30DI: p = 0.0004 / 0DI-30DI: p = 0.1105) and the area under the metatarsal heads (0DI-15DI: p = 0.0422 / 15DI-30DI: p = 0.0180 / 0DI-30DI: p = 0.9463) significantly decreased as the heel height increased. Discussion The main changes were viewed in the 30 degrees inclinations compared to 0 degrees inclination. When the toes are dorsiflexed in high heels, it stimulates the Windlass mechanism which in turn stiffens the plantar fascia and adducts the metatarsal heads, while the soft tissues shrink in response to loads. Conclusion High heels affected the shape of the transverse arch even in short term standing, and these effects increased as the height of the heel increased.
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No one discipline or person can encompass all the knowledge necessary to solve complex, ill-defined problems, or problems for which a solution is not immediately obvious. The concept of Concurrent Engineering (CE) – interdisciplinary, but with an engineering focus – was developed to increase the efficiency and effectiveness of the Product Creation Process (PCP) by conducting different phases of a product’s life concurrently. Transdisciplinary Engineering has transcended CE, emphasizing the crucial importance of interdisciplinary openness and collaboration. This book presents the proceedings of the 28th ISTE International Conference on Transdisciplinary Engineering (TE2021). Held online from 5 – 9 July 2021 and entitled ‘Transdisciplinary Engineering for Resilience: Responding to System Disruptions’, this is the second conference in the series held virtually due to the COVID-19 pandemic. The annual TE conference constitutes an important forum for international scientific exchange on transdisciplinary engineering research, advances, and applications, and is attended by researchers, industry experts and students, as well as government representatives. The book contains 58 peer-reviewed papers, selected from more than 80 submissions and ranging from the theoretical and conceptual to strongly pragmatic and addressing industrial best practice. The papers are grouped under 6 headings covering theory; education and training; PD methods and digital TE; industry and society; product systems; and individuals and teams. Providing an overview of the latest research results and knowledge of product creation processes and related methodologies, the book will be of interest to all researchers, design practitioners, and educators working in the field of Transdisciplinary Engineering.
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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.
Article
The information gleaned from kinetic and kinematic studies on foot function and gait in relation to shoes can be applied clinically after considering the key findings of the research discussed in this article. These studies demonstrate the events of the gait cycle are somewhat different from what many providers have been taught. Greater pronation of the subtalar joint when entering the propulsive period, where resupination will most likely be occurring, would be expected.
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Background and Objective: Wearing high heels is considered as normal fashion for working women that influent to decrease in balance and is a high risk of fall. Therefore, the purpose of this study was to define the factors associated with dynamic balance in workers who frequently wear high heels. Method: 28 subjects, age between 21-45 years old who have worn high heeled shoes minimally 5 centimeters, 30 hours per week for at least 1 year, completed subjective about personal demographic data, height of high heeled shoes and duration per week of wearing. They performed ankle dorsiflexion in weight bearing lunge position and Star Excursion Balance Test (SEBT). The Pearson product moment correlation coefficient statistic was used to determine correlation between these variables. Results: The results showed that SEBT score was significantly low to moderate negative correlate with personal demographic data including body weight and height and moderate positive correlate with ankle dorsiflexion ROM. There was not relationship between height of high heel shoes and duration of wearing per week. Conclusion: the workers who frequently wear high heels should consider the factors e.g. ankle dorsiflexion ROM or gastrosolous muscles flexibility, body weight, and body height which can affect dynamic balance performance intensively. If they have less gastrosolous muscle flexibility and high body weight and height, they may increase a risk of fall.
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Objective: The purpose of this study was to examine the immediate effect of different calf muscle stretching techniques on ankle dorsiflexion range of motion and dynamic balance in women workers wearing high-heeled shoes. Methods: Comparing the effects of dynamic stretching and proprioceptive neuromuscular facilitation stretching (PNF stretching) in 28 volunteers aged 21-45 years who had worn high-heeled shoes of minimum 5 centimeters, 20 hours per week for at least 1 year. Ankle dorsiflexion range of motion in weight bearing lunge position and Star Excursion Balance Test (SEBT) were performed before and after each technique of stretching. Results: The results showed ankle dorsiflexion range of motion and SEBT score significantly increased after both stretching techniques (p
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OBJETIVO: O propósito deste estudo foi avaliar a amplitude e o tempo de ativação elétrica do vasto medial oblíquo (VMO), vasto lateral longo (VLL) e vasto lateral oblíquo (VLO) durante atividades funcionais em portadoras da síndrome da dor patelofemural (SDPF). MÉTODOS: Participaram do estudo 20 mulheres, sendo dez do grupo controle e dez do grupo com SDPF. O sinal eletromiográfico do quadríceps foi detectado por eletrodos ativos diferenciais simples de superfície e um eletromiógrafo de quatro canais, durante atividades em cadeia cinética aberta (em um dinamômetro isocinético) e fechada (através de um step e durante o agachamento). Na análise estatística foram utilizados o teste t de student e uma análise de variância (ANOVA), com método pos-hoc de Tukey, com nível de significância de p<0,05. RESULTADOS: Os resultados sugerem uma menor intensidade na atividade elétrica do VMO em relação ao VLO (p=0,04) e maior retardo no tempo de ativação do VMO (p=0,0023) no grupo com SDPF considerando todas as atividades avaliadas. Houve diferença significativa do VMO em relação ao VLO nas atividades de extensão isocinética à 30º/s (p=0,042) e descida do step com 75º de flexão de joelho (p=0,038) no grupo com SDPF, e nas atividades de levantar-se de um banco (p=0,041), salto unipodal (p=0,046) e elevação dos calcanhares (p=0,004) no grupo controle. CONCLUSÕES: Nas condições experimentais realizadas, o estudo sugere um desequilíbrio na atividade elétrica e um padrão de recrutamento anormal entre os músculos VMO, VLL e VLO em sujeitos com SDPF, com maior retardo e menor amplitude de ativação do VMO neste grupo de sujeitos.
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OBJETIVO: O propósito deste estudo foi avaliar a amplitude e o tempo de ativação elétrica do vasto medial oblíquo (VMO), vasto lateral longo (VLL) e vasto lateral oblíquo (VLO) durante atividades funcionais em portadoras da síndrome da dor patelofemural (SDPF). MÉTODOS: Participaram do estudo 20 mulheres, sendo dez do grupo controle e dez do grupo com SDPF. O sinal eletromiográfico do quadríceps foi detectado por eletrodos ativos diferenciais simples de superfície e um eletromiógrafo de quatro canais, durante atividades em cadeia cinética aberta (em um dinamômetro isocinético) e fechada (através de um step e durante o agachamento). Na análise estatística foram utilizados o teste t de student e uma análise de variância (ANOVA), com método pos-hoc de Tukey, com nível de significância de p<0,05. RESULTADOS: Os resultados sugerem uma menor intensidade na atividade elétrica do VMO em relação ao VLO (p=0,04) e maior retardo no tempo de ativação do VMO (p=0,0023) no grupo com SDPF considerando todas as atividades avaliadas. Houve diferença significativa do VMO em relação ao VLO nas atividades de extensão isocinética à 30º/s (p=0,042) e descida do step com 75º de flexão de joelho (p=0,038) no grupo com SDPF, e nas atividades de levantar-se de um banco (p=0,041), salto unipodal (p=0,046) e elevação dos calcanhares (p=0,004) no grupo controle. CONCLUSÕES: Nas condições experimentais realizadas, o estudo sugere um desequilíbrio na atividade elétrica e um padrão de recrutamento anormal entre os músculos VMO, VLL e VLO em sujeitos com SDPF, com maior retardo e menor amplitude de ativação do VMO neste grupo de sujeitos.
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The purpose of this study was to assess the acute effects of vibration and stretching on passive and active forward split range of motion in elite adult female synchronized swimmers. Eleven athletes performed a passive forward split test measuring the height of the anterior superior iliac spine on both sides and an active split test on both sides by adopting an inverted split position. Then athletes were assigned randomly by right or left leg to receive vibration on one leg while stretching. The contralateral leg was stretched but did not receive vibration and served as the control. The treatment involved a 40-s exposure to vibration of the forward leg in a split and 40 s of vibration to the rear leg in a split. The athletes were then post-tested using the same protocols. The results indicated that the vibration had a statistically significant influence on passive forward split flexibility, but not active split flexibility. The results of this study confirm earlier work and further demonstrate the efficacy of vibration in enhancing range of motion in a passive split position. Given that it is often difficult to achieve large changes in range of motion with already highly trained elite athletes, this methodology shows considerable promise. Vibration may not be powerful enough to evoke changes in active range of motion in spite of the changes in passive range of motion.
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To analyze the electrical activity of the vastus medialis obliquus (VMO), vastus lateralis longus (VLL) and vastus lateralis obliquus (VLO) muscles of individuals with patellofemoral pain syndrome (PFPS) during maximum voluntary isometric contraction (MVIC) of lower leg extension with the knee at 30 degrees; to assess pain using a visual analogue scale (VAS); and to assess patellar positioning using magnetic resonance imaging (MRI). Twelve women with PFPS and 12 clinically normal women were evaluated. They performed five MVICs of lower leg extension at 30 degrees for electromyographic (EMG) analysis. Using MRI, the sulcus angle (SA), congruence angle (CA), patellar tilt angle (PTA) and patellar displacement (PD) were obtained. The following statistical tests were used: analysis of variance (ANOVA) for repeated measurements to assess EMGs; Mann-Whitney U test to analyze MRIs; Pearson's (r) correlation test between EMGs and MRIs; and one-way ANOVA to evaluate pain (p < or = 0.05). In the PFPS group, there was greater electrical activity in the VLL than in the VMO. In both groups, there was greater electrical activity in the VMO and VLL than in the VLO. In the PFPS group, the MRI showed higher SA and lower CA values, and there was a negative correlation between the VMO and the PTA. The data suggest that, in individuals with PFPS, greater electrical activity in the VLL combined with an increased SA and a decreased CA may contribute to patellar instability.
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Wearing high heels (HH) places the calf muscle-tendon unit (MTU) in a shortened position. As muscles and tendons are highly malleable tissues, chronic use of HH might induce structural and functional changes in the calf MTU. To test this hypothesis, 11 women regularly wearing HH and a control group of 9 women were recruited. Gastrocnemius medialis (GM) fascicle length, pennation angle and physiological cross-sectional area (PCSA), the Achilles' tendon (AT) length, cross-sectional area (CSA) and mechanical properties, and the plantarflexion torque-angle and torque-velocity relationships were assessed in both groups. Shorter GM fascicle lengths were observed in the HH group (49.6+/-5.7 mm vs 56.0+/-7.7 mm), resulting in greater tendon-to-fascicle length ratios. Also, because of greater AT CSA, AT stiffness was higher in the HH group (136.2+/-26.5 N mm(-1) vs 111.3+/-20.2 N mm(-1)). However, no differences in the GM PCSA to AT CSA ratio, torque-angle and torque-velocity relationships were found. We conclude that long-term use of high-heeled shoes induces shortening of the GM muscle fascicles and increases AT stiffness, reducing the ankle's active range of motion. Functionally, these two phenomena seem to counteract each other since no significant differences in static or dynamic torques were observed.
Article
The purpose of this investigation was to determine whether a graded response in gait kinematics, kinetics, and EMG occurs as shoe heel height increases. Four different shoes, including one flat shoe and three shoes with high heels, were tested in this investigation. The average heel heights of the four shoes were 1.4 cm, 3.7 cm, 5.4 cm, and 8.5 cm. Kinematics, kinetics, and muscle EMG were measured during the stance phase of gait on 13 healthy female subjects while wearing each of these 4 shoes. Systematic increases in the active vertical, propulsive, and braking forces were found as shoe height increased. Ankle and knee flexion and soleus and rectus femoris activity showed a graded response as heel height increased. One surprising result was the behavior of the maximal vertical impact force peak and the maximal loading rate during heel impact. The vertical impact force peaks and the maximal vertical loading rates were highest for the shoe with 3.7 cm heel height and lowest for the flat shoe and the shoe with heel height of 8.5 cm.
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A survey of 200 young women wearing high-heeled shoes indicated frequent complaints of leg and low back pain. Consequently, an empirical study examined the biomechanical effects of three heel heights (0, 4.5, and 8 cm), while standing stationary and while walking in five, healthy, young women. Four major biomechanical effects were observed. As heel heights increased, the trunk flexion angle decreased significantly. Similarly, tibialis anterior EMG, low back EMG and the vertical movement of the body center of mass increased significantly while walking with high-heeled shoes. Due to these added stresses, wearing of high heels should be avoided.Relevance to industryIn addition to the normal physical job stresses, women workers may experience additional biomechanical stresses placed on them by fashion demands such as high heels. All these effects can significantly increase discomfort levels in those wearing high heels.
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Exercises for the ankle are often used to improve sport performance through balance and stability or to prevent or recover from ankle injury. Ankle training programs often include exercises for the primary muscle of the lateral ankle, the peroneus longus (PL). However, many exercises for the PL are non-weight bearing and unidirectional. However, data from biomechanical studies show that peak activity of the PL occurs neither in non-weight-bearing nor during uniplanar movements. This lack of congruency may limit the effectiveness of PL training. Exercises more consistent with the biomechanical function of the PL may increase the efficacy of ankle training. This study examined and compared the electromyographic (EMG) activity of the PL during 2 exercises that specifically address the known biomechanical function of the PL and a traditional non-weight-bearing unidirectional PL exercise. Twenty healthy college-aged men and women (age 24.8 +/- 2.7 years) without history of ankle injury were examined in a single-session repeated measures design. The average root means square (RMS) values of the PL during each of the 3 exercises were measured and compared to assess for differences in magnitude of muscular activity. The RMS activity of the PL was significantly greater (p < 0.05) in each of the biomechanically correct exercises when compared with the conventional exercise. However, no significant difference was noted in EMG activity between the 2 biomechanical exercises. This study provides evidence for increased activity from the PL during 2 exercises that more accurately reflect its biomechanical function. Use of these exercises when training the PL for sports performance or rehabilitation may increase the effectiveness of ankle training programs that include PL activity.
Article
Cryotherapy and ankle bracing are often used in conjunction as a treatment for ankle injury. No studies have evaluated the combined effect of these treatments on reflex responses during inversion perturbation. This study examined the combined influence of ankle bracing and joint cooling on peroneus longus (PL) muscle response during ankle inversion. A 2x2 RM factorial design guided this study; the independent variables were: ankle brace condition (lace-up brace, control), and treatment (ice, control), and the dependent variables studied were PL stretch reflex latency (ms), and PL stretch reflex amplitude (% of max). Twenty-four healthy participants completed 5 trials of a sudden inversion perturbation to the ankle/foot complex under each ankle brace and cryotherapy treatment condition. No two-way interaction was observed between ankle brace and treatment conditions on PL latency (P=0.283) and amplitude (P=0.884). The ankle brace condition did not differ from control on PL latency and amplitude. Cooling the ankle joint did not alter PL latency or amplitude compared to the no-ice treatment. Ankle bracing combined with joint cooling does not have a deleterious effect on dynamic ankle joint stabilization during an inversion perturbation in normal subjects.