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The Effect of Heel Height on Gait and Posture A Review of the Literature

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Abstract

This article explores relevant full-text literature to reveal the effects of heel height on gait and posture and the kinetics and kinematics of the foot, ankle, knee, hip, and spine. Furthermore, special attention will be given to the implications of increased heel height for clinicians treating locomotor disorders and provide information to aid clinical decision making. Full-text articles accessed from databases including AMED, ASSIA, Blackwell Synergy, BNI, Voyager, CINAHL, ScienceDirect, and Taylor Francis inform the review.
512 November/December 2009 • Vol 99 • No 6 • Journal of the American Podiatric Medical Association
Heel height is of importance to the podiatric physi-
cian in the contexts of pathology etiology, effects of
footwear, and orthotic therapy such as the applica-
tion of heel raises. Clinical assessment of the foot is
conducted with the patient barefoot while the most
common environment of the foot in the Western world
is in a shoe, often with a positive heel. Prescriptions
for foot orthotic devices are based on barefoot assess-
ments presumed to be translatable to the foot func-
tioning in a shoe.
This article explores relevant full-text literature to
reveal the effects of heel height on gait and posture
and the kinetics and kinematics of the foot, ankle,
knee, hip, and spine. Furthermore, special attention
will be given to the implications of increased heel
height for clinicians treating locomotor disorders
and provide information to aid clinical decision mak-
ing. Literature was accessed through Metalib (compris-
ing the databases of AMED, ASSIA, Blackwell Synergy,
BNI, Voyager, CINAHL, ScienceDirect, and Taylor
Francis full-text collection) using the keywords: high
heel, high heeled, raised heel, heel height, shoe, and
footwear. In the existing literature, the distinction be-
tween raised heel and high heel remains unclear. Al-
though the attempt to define these terms is beyond
the scope of the present review, clinical reports main-
ly use the term raised heels to define what is normal-
ly referred to as high heels. However, this is currently
being clarified.1Papers that focused on increased
heel height with reference to gait and posture were
selected.
Pathologies Associated with Increased
Heel Height
Clinical presentations of the foot associated with
wearing high-heeled shoes range from general dis-
comfort2, 3 to hallux valgus and plantar calluses.4
Shoes featuring high heels do, however, often have
common elements of design that could contribute to
the above conditions, such as narrow and shallow
toe box crushing the forefoot, cut-away uppers re-
ducing midfoot support, or weak or absent fasten-
ings allowing the foot to shift in the shoe.
The risk of ankle inversion injury has been shown
to relate to increased heel height,5which may con-
traindicate the use of heel raises in patients with a
history of lateral ankle sprains unless other ankle sta-
bilizing measures are used concurrently.
Foot and Ankle Kinematics
Various studies report that when the foot is posi-
tioned in a high-heeled shoe, several changes can be
observed.6-10 For instance, the ankle joint axis moves
anteriorly and the line of gravity moves posteriorly
toward the ankle joint.6, 8 More noticeably, the foot
This article explores relevant full-text literature to reveal the effects of heel height on
gait and posture and the kinetics and kinematics of the foot, ankle, knee, hip, and spine.
Furthermore, special attention will be given to the implications of increased heel height
for clinicians treating locomotor disorders and provide information to aid clinical decision
making. Full-text articles accessed from databases including AMED, ASSIA, Blackwell
Synergy, BNI, Voyager, CINAHL, ScienceDirect, and Taylor Francis inform the review. (J
Am Podiatr Med Assoc 99(6): 512-518, 2009)
*Faculty of Health, University of Plymouth, Plymouth,
United Kingdom.
†Faculty of Health, Staffordshire University, Stoke on
Trent, United Kingdom.
Corresponding author: Emma E. Cowley, MSc, Faculty
of Health, University of Plymouth, Derriford Rd, Plymouth,
Devon, PL6 8BH United Kingdom. (E-mail: emma.cowley
@plymouth.ac.uk)
The Effect of Heel Height on Gait and Posture
A Review of the Literature
Emma E. Cowley, MSc*
Thierry L. Chevalier, BSc†
Nachiappan Chockalingam, PhD†
BASIC SCIENCE REVIEW
Journal of the American Podiatric Medical Association • Vol 99 • No 6 • November/December 2009 513
becomes immediately shorter because of the arch ris-
ing.10 Ricci and Karpovich9studied women’s arch
height and found changes after a day wearing high
heels: heel heights of 0.6 to 2.1 cm resulted in an arch
height that was 0.3 cm lower; heel height of 6.2 to 7.1
cm resulted in an arch height that was 0.4 cm higher.
Moreover, Frey et al11 found that 86% of American
women wore shoes that were smaller than their feet,
possibly for reasons of reducing the space for foot
motion in the shoe. The inference from this evidence
is that if arch height increases because of high heels,
the foot will shorten, causing the shoe to become too
long for the foot, which would alter fit, comfort, and
stability. On the contrary, if the arch height is reduced
by wearing low-heeled shoes, the foot length will in-
crease when the shoes are worn, which potentially
could cause the foot to extend further into the shallow
distal end of the toe box. In another study, Schwartz
and Heath10 reported the immediate changes in foot
length with increased heel height. In agreement with
previous studies,9-11 it was observed that the heel-to-
ball length of the foot was reduced in high heels ac-
companied by increased arch height.
Broch et al12 reported that in high heels, the foot at-
tempts to slide distally in the shoe. Since the foot be-
comes shorter when wearing high-heeled shoes, it is
inevitable that the foot will slide forward, creating
compression between the vamp and the dorsum of the
foot. Such compression could be sufficient to elicit
pain in some feet. Prevention of this motion is normal-
ly achieved with substantial upper contact with the
foot and broad ankle fastenings, which unfortunately
are often missing in women’s high-heeled shoes.12, 13
Ebbeling et al7investigated lower-limb biomechan-
ics as a function of heel height. It was found that as
heel height increases, a graded increase in maximum
rearfoot eversion angle could be observed until the
highest heel condition (7.62 cm). In this heel height
condition, the angle reduces to less than that of a no-
heel elevation. However, the time taken to reach the
maximum rearfoot eversion angle is said to increase
linearly with heel height. This sudden reduction of
rearfoot eversion angle with 7.62-cm heel height could
be attributed to the increased work of the perimalleo-
lar muscles attempting to maintain stability of the
ankle joint.7This also has the indivertible effect of re-
ducing the available motion at the subtalar joint by
default of the perimalleolar muscles’ action. Ebbeling
et al7also postulated that a reduction in subtalar joint
eversion may be attributable to the peroneal muscles
having to work in tonic, isometric contraction to main-
tain stability of the plantarflexed ankle joint.
As previously mentioned, the risk of ankle inver-
sion injury has been shown to relate to increased heel
height.5In high-heeled shoes, the ankle joint has greater
freedom of frontal plane motion (and is therefore less
mechanically stable) because of the reduced articular
congruence between the talus and tibiofibular mor-
tice. This reduced articular congruence can be attrib-
uted to the plantarflexed position of the foot. Addi-
tionally, Payne et al14 found that feet with laterally
deviated subtalar joint axes, especially when com-
bined with a plantarflexed ankle joint, are at risk of
inversion ankle injury.14 Gollnick et al15 found an aver-
age of 20°ankle joint plantarflexion in subjects wear-
ing high-heeled shoes. This highlights the importance
of the musculoskeletal system having the capacity to
adapt to increased heel height. Ebbeling et al7also
found that the ankle joint is able to gain a dorsiflexed
position in the midstance phase of gait with heel
heights less than 7.62 cm. However, at 7.62 cm the
ankle does not recover from its plantarflexed position
even in swing phase emulating an equinus gait.15, 16
Although the vast majority of articles identified
kinematic changes caused by high heels, Hansen and
Childress17 determined that high-heeled shoes had no
significant effect on the ankle-foot rollover shape.
However, the authors indicated that the differences
could be seen with the use of very high heels (higher
than 5.0–6.0 cm). Furthermore, it is suggested that
the ankle cannot always fully compensate for the
foot’s unnatural position.17
In contrast to the studies mentioned above, the
use of heel raises or high-heeled shoes could also be
beneficial in treating specific pathologies. Cyriax18
postulated that heel elevation can decrease plantar
fascia strain. Recently, further cadaveric studies19 and
finite element modeling confirmed these findings. Ac-
cording to the latter,20 a heel height of 5.08 cm would
be beneficial in the treatment of plantar fasciitis.
Kogler et al19 also concluded that the inclusion of a
contoured, declined area of a shoe between the heel
and forefoot, along with a raised heel, reduced the
strain in the plantar fascia in some of the feet tested.
Kinetics
Perry et al21 conducted a study on running shoe com-
fort and concluded that increased pressure caused
by reduced contact area may contribute to pain. More-
over, Van der Leeden et al22 established a relationship
between joint damage and increased forefoot pressure.
In the same way, a reduction in weightbearing area in
high-heeled shoes can result in pain.23 So if the pos-
ture acquired when wearing high-heeled shoes places
demands on a joint or muscle beyond its capabilities,
it may increase the tissue’s stress to a point where in-
jury occurs.24 As a result, numerous studies3, 6, 8, 25-30
514 November/December 2009 • Vol 99 • No 6 • Journal of the American Podiatric Medical Association
have consistently demonstrated that high-heeled
shoes increase the maximum peak pressure, total
pressure, and duration of pressure under the medial
forefoot during gait. In addition, Yung-Hui and Wei-
Hsien3also demonstrated that the impact force dur-
ing gait will increase as a function of heel height.
Snow et al29 indicated that wearing high heels results
in higher overall pressures across the metatarsal
heads. However, it was suggested that additional
quantitative studies should be undertaken to assess
the long-term effects of wearing high-heeled shoes.3
Schwartz et al28 demonstrated that pressure under the
forefoot increased and heel pressure decreased at a
5-cm heel height. This suggests that there is an anteri-
or weight transfer mechanism occurring with the use
of high-heeled shoes. Soames and Clark30 concurred
with these findings, stating that mean pressure under
the first and second metatarsal heads were highest
and pressure under the lateral three metatarsal heads
decreased to zero as heel height increased. More re-
cently, Nyska et al27 confirmed these findings, indicat-
ing that the forefoot pressure not only increases but
transfers to the first metatarsal head while the lateral
forefoot unloads with increased heel height. In addi-
tion, the pressure increases under the first metatarsal
head double with the use of high-heeled shoes.13 It
was also found that the fifth metatarsal head un-
loaded before the end-of-stance phase with a shorter
force-time integral than the first metatarsal head.27
This would suggest that the weight transfer mecha-
nism happens not only in an anterior but also a medi-
al direction.
Furthermore, Nyska et al27 observed that the pres-
sure-time integral increased by 35% at the first metatar-
sal head as heel height increased. However, Gastwirth
et al25 performed an electrodynographic study of two
different heel heights and found an increase in dura-
tion of forefoot loading, but pressure did not increase.
Although the majority of evidence suggests that a
significant amount of weight is transferred to the fore-
foot when heel height is increased, some controversy
still remains with regard to increased forefoot pres-
sure.25 Furthermore, Yung-Hui and Wei-Hsien3estab-
lished that there are advantages to using shoe inserts
such as total contact insoles, even in high-heeled
shoes. The insert not only significantly reduces the im-
pact force, but also increases the perceived comfort.
This is an area that warrants further research.
As previously mentioned, when walking with high
heels of 7.62 cm or higher, the ankle cannot recover
from its plantarflexed position, even in the swing
phase. If the foot cannot achieve a plantigrade pos-
ture in gait, the pressure-time integral at the forefoot
will increase, and the rearfoot will unload by compar-
ison.15 A study by Özdemir et al31 indicated that al-
tered heel fat pad properties may contribute to heel
pain in barefoot gait and lead to antalgic changes in
gait pattern. An extrapolation of this finding could re-
late to the metatarsal fat pad with increased heel
height since the forefoot pressure-time integral in-
creases in high-heeled gait.16
In order to create tension prior to achieving a plan-
tarflexion motion, the triceps surae muscles have to
shorten concentrically, leaving a reduced range of
concentric contraction available for creating motion.32
This shortening of the triceps surae muscles will re-
sult in insufficient muscle shortening capacity to cre-
ate proper motion. As well as shortening the muscle
length, high heels will affect the lever arm of the tri-
ceps surae muscles by shortening it. This implies that
the muscles need to produce more force in order to
achieve the same moment of force. The Achilles ten-
don reduces tension as the ankle joint plantarflexes.6, 8
Since perimalleolar muscles can no longer produce
the same tension in high heels as when barefoot, con-
trol of the ankle, subtalar, and talonavicular joints is
compromised. Yet habitual high-heel wearers seem to
develop greater strength through range of ankle joint
plantarflexion,33 compensating for the loss of control.
It is anecdotally noted that the triceps surae contrac-
ture seen with chronic use of high heels34 is possibly
attributable to the triceps surae shortening after
many years of attempting to control the posture of a
high-heel wearer.
Electromyographic studies reveal further changes
provoked by wearing high heels. Basmajian and Bent-
zon35 discovered that the lateral head of the gastroc-
nemius muscle maintained constant contraction in
high heels (6 cm) compared with barefoot conditions.
Joseph36 added that tibialis anterior also increased its
activity with increased heel height, potentially con-
tributing to the stability of the ankle joint and reduc-
ing the pronation moment. Consequently, since tibialis
posterior, like the triceps surae, is similarly mechani-
cally compromised in this posture, overall instability
at the rearfoot is increased.
Stefanyshyn et al37 observed a decrease in ankle
joint plantarflexion moment, possibly attributable to
functional shortening as described above, but no
change in dorsiflexion moment as heel height in-
creased. In high heels of 8.5 cm, the need to create
plantarflexion motion is somewhat negated because
the foot is already in a plantarflexion position. The
issue is then to create sufficient tension to achieve
ankle joint stability by the plantarflexors.
A study by Esenyel et al38 focusing on kinetic pa-
rameters indicated a reduction in triceps surae muscle
moment, attributable to induced muscle weakness in
Journal of the American Podiatric Medical Association • Vol 99 • No 6 • November/December 2009 515
time. Although Kerrigan et al42 originally did not con-
trol heel height among their subjects, a more recent
study44 attempted to assess the effects of moderate
heel heights. It was found that wearing even a moder-
ately high-heeled shoe (3.8 cm) results in an increased
peak external varus knee moment in late stance as
well as an increased knee flexor moment of force in
the first half of the stance phase.44
A recent study37 reported a 23% increase in hip flex-
or work in response to a higher hip extension mo-
ment in high-heeled gait at preswing and swing phases
of gait. However, in loading response, the hip flexors
contribute negligibly to hip flexion since ground reac-
tion forces shift anterior to the hip joint. Likewise,
the reported 200% increase in knee extensor activity37
could be indirectly responsible for the reduction of
hip flexor moment.
Stefanyshyn et al37 also observed a 25% increase in
hip and knee varus moments in high-heeled gait. Esen-
yel et al38 demonstrated that the hip abductors showed
an 11% increase in work during stance phase, coun-
tering the hip varus moment created by high-heeled
gait. Another study35 focusing on muscle activity in
gait with increased heel height reported an additional
phase of activity of the gluteus medius muscle during
high-heeled gait. This may account for the findings of
reduced varus torque in some knees and hips,37 as the
gluteus medius could be resisting pelvic tilt (or drop)
in the frontal plane to a greater extent than in bare-
foot gait.
Spine
Opila-Correia45 compared experienced and inexperi-
enced wearers of high heels, postulating that there
would be a difference in the effect on posture be-
tween the two groups. This study is of particular in-
terest, since Opila et al46 noted that previous studies
had not taken into account the effects of habituation
when wearing high heels. Opila-Correia45 found that
immediate changes occurred as a result of wearing
high-heeled shoes: increased hip and knee flexion
and increased spinal lumbar lordosis in inexperi-
enced wearers of high heels. Furthermore, it was re-
ported that this change in lordosis was not evident in
experienced wearers, indicating the potential habitua-
tion in experienced wearers of high heels.
The influence of age on postural changes resulting
from prolonged use of shoes with increased heel
height has also been studied. A clinical perception47
that was initially confirmed48, 49 implies that wearing
high-heeled shoes increases lumbar lordosis. Opila-
Correia45 indicated that using high heels did result in
an increase in lumbar lordosis in younger subjects,
high heels. The study also reported a reduction in the
strength of triceps surae muscles by 29%. To overcome
the muscle weakness and plantarflexed ankle joint in-
stability, the gastrocnemius muscle tends to alter its
phasicity and becomes more tonic than phasic.35
Knee and Hip
Ebbeling et al7reported that the time taken for the
knee to reach maximum flexion in gait while wearing
high-heeled shoes was longer than that with no heel
inclination. Other studies have also found that the
knee does not achieve the same amount of flexion in
high-heeled shoes compared to low-heeled shoes.39, 40
Gehlsen et al39 studied the different effects of varying
heel height on knee activity during gait. It was found
that the mean values for knee flexion-extension dur-
ing the swing phase was significantly different and
decreased with high heels. However, this study pres-
ents a major methodological limit. The subjects with-
in the study wore their own high-heeled shoes and
the heel height parameter was not controlled, which
varied from 6.0 cm to 10.7 cm. Nonetheless, the re-
duced knee flexion induced by wearing high heels
will also result in a reduced amplitude sine wave pat-
tern of the center of mass, compared with that of
barefoot gait.40 With this reduced dampening action
of the knees, there is a potential for shock to travel
undampened up to the spine.
Since the gastrocnemius and the soleus have both
been reported to increase their tonic behavior in high-
heeled gait, it is possible that the phasic events sur-
rounding the popliteus muscle unlocking the knee in
the preswing phase of gait may be disrupted.41 With
the changes in triceps surae and perimalleolar muscle
activity and the timing of knee flexion plus rearfoot
eversion angle, Ebbeling et al7hypothesized that the
mechanism for knee unlocking that enables knee flex-
ion may be disrupted. This would then suggest that
the knee would be more injury-prone in high heels.
Additionally, in a study by Stefanyshyn et al,37 a 200%
increase in concentric knee extensor activity was ob-
served, compared to barefoot gait during this phase.
This considerable increase in moment of force, creat-
ed by the knee extensor muscles, counters the knee
flexion moment of force and therefore reduces the
amount of knee flexion during the swing phase in
high-heeled gait.
Kerrigan et al42 found parallel outcomes when
measuring the varus moment of force across the knee
in high-heeled shoes with a heel height higher than
5.0 cm, averaging 6.0 cm. It was suggested42, 43 that the
increase in varus moment could have destructive
consequences on knees subjected to such stress over
516 November/December 2009 • Vol 99 • No 6 • Journal of the American Podiatric Medical Association
but on the contrary, decreased in older subjects. Al-
though these findings add nuance to the earlier study
by stating that the effects of high heels on lumbar lor-
dosis are age dependent, some studies47, 50 found no
significant difference in average lumbar lordosis be-
tween heel heights (1.91, 3.81, 7.62 cm).
Lee et al51 found a 16°increase in spinal flexion be-
tween static and dynamic measurements in high-
heeled conditions. They showed that in gait, a 1°in-
crease in heel height results in a 1°decrease in lumbar
spinal flexion. A corresponding change in erector
spinae muscle activity accompanied the reduction in
flexion as the electromyogram signal at the fourth
and fifth lumbar vertebrae level was significantly high-
er with increased heel height in gait. On the other
hand, Joseph36 found no change in erector spinae ac-
tivity in women walking in low-elevated heels. Ac-
cording to a study by Bendix et al,52 the lumbar lordo-
sis and pelvic inclination was reduced with increased
heel height. However, the muscle activity remained
the same, unaffected by the change in heel height.
Gait, Posture, and Balance
The design of high-heeled shoes is highly variable,
ranging from platform to stiletto or tapered heel. A
study by Lord and Bashford53 demonstrated that pos-
tural stability in wearers of high-heeled shoes is im-
proved by increasing the area of the base of the heel.
A further study of high-heeled gait54 indicated that to
improve stability of the high-heel wearer, the center
of the heel should be medial, by 2 to 4 mm, to the
midline of the shoe. A recent study by Lindemann et
al33 reported no difference in the balance of octogenar-
ian women introduced to wearing 2-inch high-heeled
shoes. They compared these findings to women of the
same age who had time to habituate to the increased
heel height over a 5-week period. The study conclud-
ed that either no habituation was required or habitua-
tion took longer than 5 weeks in octogenarian women.
Similarly, no muscle contracture was reported in the
study, indicating that such change in this group may
take longer than 5 weeks.
Investigations by Lee et al51 into gait in high heels
demonstrated that stance phase time in high-heeled
gait increased when compared to low-heeled gait.
Furthermore, the subjects in high-heels walked more
slowly, had shorter strides and longer stance time
than when in low heels, while cadence remained un-
changed. In another study, Lee et al55 also indicated
that feet become more internally rotated, when com-
pared to the barefoot position in high heels than low
heels. Opila-Correia,45 however, found no change in
cadence, velocity, and percentage stance time relat-
ing to age.
In normal adult gait, the center of mass moves in a
way that produces a sine wave pattern that is indica-
tive of efficiency of gait with correct timing of gait
phases.56 High-heeled gait has been seen to disrupt
this ideal pattern as reported by Stefanyshyn et al,37
who noted how the acceleratory and deceleratory
forces increased in high heels resulting in loss of flu-
idity of gait, hence making gait less efficient. Accord-
ing to a recent study,45 in high-heeled shoes, subjects
aged between 23 and 42 years increased knee stabi-
lization using their quadriceps muscles.38
The postural changes caused by high heels is an
overall increase in stiffness of the kinetic chain, which
renders tissues more prone to injury from shock and
aberrant force vectors over time.42, 46 The risk of injury
increases further with a higher magnitude of vertical
ground reaction forces in high heels.7The increased
vertical ground reaction force and the loss of lumbar
lordosis increase the axial compression of interverte-
bral discs. These effects, combined with aging, imply
that the older population is more prone to back pain
and injuries. Additionally, the effects are amplified
with the more active erector spinae muscles, which
act in part to compress the spine.51
Other Effects of High Heels
Changes in gait with increased heel height have been
researched for many years, with recent studies using
complex kinematic, kinetic, and physiologic tech-
niques.7, 38 Mathews and Wooten57 found that oxygen
consumption increases when walking in high-heeled
shoes. Studies by Mathews and Wooten57 and Ebbel-
ing et al7revealed that high-heeled gait is more energy
consuming than low-heeled gait and can lead to fatigue,
which reduces reflex and voluntary response rates as
well as affecting muscle phasicity and strength.58
Interestingly, Ebbeling et al7found no significant
differences for any kinematic parameters between
experienced (and, therefore, possibly contractured)
and inexperienced wearers of high heels, a finding
contradicted in a study by Kuni and Schmitt.59
Conclusions
This review has illustrated the effects of increased heel
height on a normal adult population. Considerations
for clinicians from this review include acknowledg-
ment of the effects, both beneficial and detrimental,
of increased heel height in the context of pathology
or impaired function.
Journal of the American Podiatric Medical Association • Vol 99 • No 6 • November/December 2009 517
Financial Disclosure: None reported.
Conflict of Interest: None reported.
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... However, some researchers have reported that the use of these shoes has subsequently had an adverse effect on different body structures. 4,5,6 Studies suggested that the use of high heels can contribute to the incidence and progression of knee pain, 7,8 an increased predisposition toward degenerative knee osteoarthritis 8,9 , low back pain due to increased spinal curvature 10,11 and changes in gait pattern, such as walking speed and mobility. [12][13][14][15] Studies established that the practice of wearing high-heeled shoes for an extended period increases plantar flexion and leads to decreased triceps surae muscle extensibility and decreased ankle joint range of motion. ...
... this can lead to Achilles tendinitis, gastrocnemius strain, and plantar fasciitis. 4,5 As a result, calf muscle stretches are commonly prescribed in an attempt to increase ankle joint dorsiflexion and to reduce the symptoms of such disorders. [16][17][18][19][20][21] Physical therapists are using a wider approach of interventions to maintain and increase flexibility, reduce joint stiffness, avoid dysfunction and deformities resulting from muscle contractures. ...
Article
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Objective: This study aimed to observe the influence of two manual techniques in improving the flexibility of the triceps surae muscle in working females wearing high heels. Methods: This study is based on a pretest-posttest experimental control group design, which included forty-five working females wearing high heels. All the participants were assigned randomly into three groups A, B and C. Group A received a hot pack treatment for 20 minutes followed by a Muscle Energy Technique (MET) which was repeated four times (10-second contraction, 5-second relaxation). Group B received a hot pack intervention for 20 minutes followed by static stretching which was repeated five times (30-second hold, 15-second rest between each repetition). Group C received only a hot pack intervention for 20 minutes. Active ankle dorsiflexion range of motion (ADFROM) on day 1 pre-intervention (baseline) and post-intervention on Day 1, 3, 5 and 8 was taken as an outcome measure. Results: For the variable ADFROM, the data analysis showed insignificant differences (p<0.05) between and within the groups at Day 1 post-intervention and when comparing the scores at Day 1 post-intervention with baseline scores respectively. Additionally, both experimental groups A and B showed a significant difference (p>0.05) against control group C, though an insignificant difference (p<0.05) between them at Day 5 post-intervention and the Day 8 follow-up, respectively. Conclusion: This study concluded that both manual techniques are equally effective in improving the flexibility of the triceps surae muscle in working females wearing high heels. Key Words: Flexibility, Muscle Energy Technique, Static stretching, Triceps surae muscle. Footwear, Manual therapy
... Increased lumbar lordosis [21] associated with high-heeled shoes has been reported for inexperienced wearers [9,22], or adolescent experienced wearers [15]. Cowley et al. [23] concluded in their review that increased lumbar lordosis angles were found predominantly in inexperienced users. Some authors suggest that high-heeled shoes do not affect lumbar lordosis [12]. ...
... Increased lumbar lordosis [21] associated with high-heeled shoes has been reported for inexperienced wearers [9,22], or adolescent experienced wearers [15]. Cowley et al. [23] concluded in their review that increased lumbar lordosis angles were found predominantly in inexperienced users. Some authors have suggested that high-heeled shoes may not affect lumbar lordosis [12]. ...
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The influence of high-heel footwear on the lumbar lordosis angle, anterior pelvic tilt, and sacral tilt are inconsistently described in the literature. This study aimed to investigate the impact of medium-height heeled footwear on the static posture parameters of homogeneous young adult standing women. Heel geometry, data acquisition process, as well as data analysis and parameter extraction stage, were controlled. Seventy-six healthy young adult women with experience in wearing high-heeled shoes were enrolled. Data of fifty-three subjects were used for analysis due to exclusion criteria (scoliotic posture or missing measurement data). A custom structured light surface topography measurement system was used for posture parameters assessment. Three barefoot measurements were taken as a reference and tested for the reliability of the posture parameters. Two 30-degree wedges were used to imitate high-heel shoes to achieve a repeatable foot position. Our study confirmed the significant (p < 0.001) reduced vertical balance angle and pelvis inclination angle with large and medium-to-large effects, respectively, due to high-heel shoes. No significant differences were found in the kyphosis or lordosis angles. High-heeled shoes of medium height in young asymptomatic women can lead to a straightening effect associated with a reduced vertical balance angle and decreased pelvic inclination.
... These changes in the muscles activation system during gait with HHS are still not well documented and the assessment methods are varied (from electromyography, to video or sensory methods). In addition to these aspects, it is necessary to analyze and approach the HHS port by female subjects as a series of studies [6] show that approximately 86% of "American women wore shoes that were smaller than their feet, possibly for reasons of reducing the space for foot motion in the shoe. The inference from this evidence is that if arch height increases because of high heels, the foot will shorten, causing the shoe to become too long for the foot, which would alter fit, comfort, and stability" [6]. ...
... In addition to these aspects, it is necessary to analyze and approach the HHS port by female subjects as a series of studies [6] show that approximately 86% of "American women wore shoes that were smaller than their feet, possibly for reasons of reducing the space for foot motion in the shoe. The inference from this evidence is that if arch height increases because of high heels, the foot will shorten, causing the shoe to become too long for the foot, which would alter fit, comfort, and stability" [6]. Interesting aspects are identified in HHS port analyzes not only in the normal walking cycle, but also in running, jumps or stepping, in more complex dynamic actions and leading to higher instability rates, with different studies showing that there is an interaction between speed travel and height of HHS [7]. ...
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Gait cycle analysis is a comprehensive source of information, usable in the medical field, in locomotion, sporting recovery procedures or to increase performance in various sporting fields. Study methods of walking cycle parameters are very diverse, starting from biomechanical analysis, computer simulations and modelling, and completing with video analysis of kinematic and dynamic parameters. The use of optical and video methods is very widespread in all medical, sporting, ergonomic and even economic fields. Thus, the first part of the paper analysis the general aspects regarding the use of optical methods of acquisition and processing of video sequences of the normal gait cycle. Also, in the same context of the introductory part of the paper the aspects of the biomechanics of the normal and high heels cycle for the females are presented. In the second part of the paper is presented an experimental setup for investigating, with the sample of subjects chosen, the cycle of gait with shoes having different dimensions of the heel height. In the third part of the paper are presented the recordings made on footscan pressure plate and also the data acquisition on the especially sensory insole worn by the subjects. In the final part of the paper are presented the results of the processing of this information and the conclusions from the experiment.
... It was found in a recent study that high heeled shoes can be a source of low back pain, fatigue, and pain in 20 toes and feet. Another study found that high heeled shoes can be a cause of low back pain because even if they are worn for a shorter duration of the time, as they have the capability to disrupt the biomechanics 21 of the body. The results of this study are contradictory to our results as in our research it was found that high heeled shoes were not a causative factor for the low back pain. ...
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Objective: To find that the association of the low back pain with the use of the high heel shoes. Methodology: In this descriptive cross-sectional study, survey method was used and self developed questionnaire was distributed among students of Sargodha Medical College by convenient sampling method. Duration of study was six month. The inclusion criteria were the young females who had age between 18 and 24 years and wore high heel shoes for more than previous six months. Results: Out of 100 students, 42 had bad experiences while wearing heels. Out of these 42, 33 had fatigue and nine had back pain. Pearson association 0.063 showing a weak association and results were not significant. Conclusion: Low back pain in students wearing high heel shoes is not associated with their high heel shoes. Key words: High heeled, low back pain, biomechanics, kinesiology, heel pain, calf pain.
... Wearing high-heeled shoes is one of the factors that most affects general gait and posture characteristics [12]. The influence of high heels on gait has been studied in the scientific literature from many viewpoints, such as clinical [13], biomechanical [14,15], energetic [16], kinetic [2,17,18] and kinematic [2,19,20]. ...
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Gait is influenced by many factors, but one of the most prominent ones is shoe heel height. Optical motion tracking technology is widely used to analyze high-heeled gait, but it normally involves several high-quality cameras and licensed software, so clinics and researchers with low budgets cannot afford them. This article presents a simple, effective technique to measure the rotation angles on the sagittal plane of the ankle (tibiotalar) and toe (metatarsophalangeal) joints when no shoes (0 cm heel) and high-heeled shoes (2, 6 and 10 cm heels) are worn. The foot’s position was determined by a set of equations based on its geometry and video analysis techniques with free software (Tracker). An evaluation of the spatio-temporal variables confirmed observations from previous studies: increasing heel heights reduces gait cycle length and speed but does not change cadence. The range of movement at the tibiotalar joint progressively narrowed from 28° when no heel height was worn to 9° when a 10 cm heel was used, and these reductions ranged from 30° to 5° for metatarsophalangeal joints, respectively. This aligns with other authors’ previous studies, and confirms that the proposed method accurately measures kinematic ankle–foot set changes when wearing high heels.
... Heeled footwear affect gait stability and can make the user prone to injuries. [1][2][3][4][5]. While, soft soled shoes are used as orthotics to redistribute load on the foot for people with movement disorders like stroke or Parkinsons. ...
Article
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.
... Use of high-heeled footwear began more than 1000 years ago and resulted in the development of changes in gait, posture and the kinematics and kinetics of the spine, pelvis, hip, knees and ankle (Cowley, Chevalier, & Chockalingam, 2009;Yung-Hui & Wei- Hsien, 2005). Thirty-seven percent to 69% of women are reported to use high-heeled shoes daily (Esenyel, Walsh, Walden, & Gitter, 2003;Organization, 1986;Yung-Hui & Wei-Hsien, 2005). ...
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Objectives: To evaluate the relationship between high-heeled shoes of varied heel height and bladder neck elevation in women. Methods: A cross-sectional, exploratory design was applied. Twenty-three continent 18–49-year-old women performed pelvic floor muscle (PFM) contractions while standing in high-heeled shoes of varied heel height. Transabdominal ultrasound was used to evaluate bladder neck elevation in ventral-cranial direction from the resting position during maximum voluntary contraction (MVC) of pelvic floor muscles. Results: Significantly greater bladder neck elevation was demonstrated in neutral ankle position compared to the two- (0.27 [95% CI 0.14–0.39] p < 0.001) and three-inch high-heeled conditions (0.37 [95% CI 0.21–0.53]) p < 0.001). A non-significant association was found between lumbopelvic angle and bladder neck elevation in the ankle dorsiflexion and the two- and three-inch high-heeled conditions. Conclusion: Significantly lower bladder neck elevation in high-heeled conditions indicates that pelvic floor muscle contraction to elevate bladder neck might not be as strong while wearing high-heel shoes as it is while standing bare feet. Further studies with larger sample size are required to evaluate the possible relationship between varied heel height, bladder neck elevation, and urinary incontinence in women.
Article
Background: Shoe heel height is considered to influence prosthetic alignment, walking comfort, and gait symmetry in people with a transtibial amputation (TTA). However, research on the effect of heel height is scarce, and no evidence is available on the effects of variations smaller than 20 mm. These small heel height variations between store-bought shoes are often overlooked by people with an amputation and may cause secondary musculoskeletal problems in the long term. Objective: To examine the effects of small increases in heel height on gait symmetry in people with a TTA and healthy individuals. Study design: Experimental repeated measures study. Methods: Fourteen participants with a TTA and 15 healthy controls were included. Pressure data, spatiotemporal data, and experienced walking comfort were measured during walking with four heel height conditions: original height and increased heights of 3, 5, and 8 mm. Symmetry in center of pressure velocity (VCOP), gait parameters, and experienced walking comfort were compared between the heel heights and between healthy controls and prosthetic walkers. Results: Increased heel height resulted in a significant decrease in VCOP symmetry (P = 0.001) and experienced walking comfort (P < 0.001). The VCOP trajectory of the prosthetic leg mainly differed within the first 14.5% of the stance phase. Healthy individuals showed better VCOP symmetry in all conditions (P < 0.001). Conclusions: Healthcare professionals should advice their clients to be alert of small heel height differences between store-bought shoes, especially those larger than 5 mm. A prosthetic alignment adjustment should be considered when purchasing new shoes.
Article
Background High-heeled shoes has 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 mas (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.
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The authors undertook a study to evaluate the prevalence of ankle equinus and its potential relationship to high plantar pressure in a large, urban population with diabetes mellitus. The first 1,666 consecutive people with diabetes (50.3% male; mean [+/-SD] age, 69.1 +/- 11.1 years) presenting to a large, urban, managed-care outpatient clinic were enrolled in this longitudinal, 2-year outcomes study. Patients received a standardized medical and musculoskeletal assessment at the time of enrollment, including evaluation at an onsite gait laboratory. Equinus was defined as less than 00 of dorsiflexion at the ankle. The overall prevalence of equinus in this population was 10.3%. Patients with equinus had significantly higher peak plantar pressures than those without the deformity and were at nearly three times greater risk for presenting with elevated plantar pressures. There were no significant differences in age, weight, or sex between the two groups. However, patients with equinus had a significantly longer duration of diabetes than those without equinus. Having a high index of suspicion for this deformity and subsequently addressing it through conservative or surgical means may help to reduce the risk of foot ulceration and amputation.
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Clinical Sports Medicine has been fully updated from the popular 2nd edition (2000). It is even more practical, now superbly illustrated, easy-to-read and packed with substantially updated and new material. There are samples of several chapters online including the whole "Pain in the Achilles region" chapter. This book describes a completely symptom-oriented approach to treating clinical problems.
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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 triaxial electrogoniometer was used along with a Locam camera to measure knee rotation and gait characteristics of nineteen female college students while walking on a treadmill under three experimental conditions (barefoot, running shoes and high heels). Range of valgus-varus, flexion-extension and internal-external rotation during the swing and support phases, and maximum flexion during the swing walking step phase were studied. Significant differences (p < 0.01) were found among the three heel height treatments for range of knee flexion-extension during the swing walking phase and for internal-external rotation during the swing walking phase. Significant differences (p < 0.01) were also found between the high heeled swing phase mean value for internal-external rotation and the barefoot treatment mean values. ANOVA indicated a significant difference among the three experimental treatments for all distance and temporal variables studied.
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Twenty-four non-symptomatic subjects were recruited for this study. They were evaluated for foot-type and selected static parameters to determine their influence on kinematic and kinetic variables measured during barefoot overground walking. Foot-type and lower extremity characteristics were examined through the measurement of arch index, range of motion measurements of the ankle, subtalar, first metatarsal and hip joints, and the measurement of the orientation of the calcaneus and tibia. Measurements collected during the support phase of the gait cycle included kinetic measures via a force platform, kinematic measures of the knee joint using a three-dimensional electrogoniometer and kinematic measures of the rearfoot angle using a high speed motion camera. Angle of gait and step parameters were also measured utilizing an inked paper track system. Using the static evaluation measures to predict dynamic gait resulted in significant canonical correlations between first ray mobility and rotational values at the knee, first ray mobility and anteroposterior ground reaction force variables, and static hip internal-external rotation with varus-vaigus motion at the knee. The results suggest that static lower extremity measures have limited value in predicting dynamic lower extremity function to any great degree.
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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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Many minor ankle and foot injuries have occurred in the past year while individuals were wearing the fashionable, elevated or 'platform' shoes. This article reports 6 severe ankle fractures and fracture dislocations with a minimum of trauma, when the foot twisted on an uneven surface causing a sudden, severe force. The results were 4 fracture dislocations of the ankle necessitating open reduction and internal fixation, one undisplaced ankle fracture, and one calcaneous fracture requiring plaster immobilization. These shoes may have soles elevated as much as 4 cm and the heels 15 cm. They are worn by male and female alike. Our experience was with 3 males and 3 females whose ages ranged from 26 to 46 yr. The injuries resulted in lost work time with the potential for future disability in the involved joints. Physicians and patients should be made aware of the serious potential hazards to persons wearing 'platform' shoes.
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The purpose of this study was to investigate the effects of increased heel height in women's shoes on foot pressure during walking. An increase in heel height increased the maximum peak pressure under the metatarsal heads in the forefoot, decreased the time to maximum peak pressure under the metatarsal heads, and increased the rate of loading to the metatarsals during early support. The higher pressures noted with increased heel height were accompanied by a more uniform distribution of pressure beneath the forefoot. These findings may denote increased stress to the various tissues in the foot when walking in high heeled shoes, which may contribute to deleterious orthopaedic changes. Quantitative studies need to be conducted to determine whether orthopaedic changes occur with prolonged wearing of high heeled shoes.