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BACKGROUND: It has been proposed that high-heeled shoes may contribute to the development and progression of knee pain. However, surprisingly little research has been carried out on how shoe heel height affects muscle activity around the knee joint. The purpose of this study was to investigate the effect of differing heel height on the electromyographic (EMG) activity in vastus medialis (VM) and vastus lateralis (VL) during a sit to stand activity. This was an exploratory study to inform future research.
METHODS: A repeated measures design was used. Twenty five healthy females carried out a standardised sit to stand activity under 4 conditions; barefoot, and with heel wedges of 1, 3, and 5 cm in height. EMG activity was recorded from VM and VL during the activity. Data were analysed using 1x4 repeated measures ANOVA.
RESULTS: Average rectified EMG activity differed with heel height in both VM (F2.2, 51.7 = 5.24, p < 0.01), and VL (F3, 72 = 5.32, p < 0.01). However the VM: VL EMG ratio was not significantly different between conditions (F3,72 = 0.61, p = 0.609).
CONCLUSIONS: We found that as heel height increased, there was an increase in EMG activity in both VM and VL, but no change in the relative EMG intensity of VM and VL as measured by the VM: VL ratio. This showed that no VM: VL imbalance was elicited. This study provides information that will inform future research on how heel height affects muscle activity around the knee joint
Changes of bioelectrical activity in cervical paraspinal muscle during gait in low and high heel shoes.
Mika A, Oleksy L, Mikołajczyk E, Marchewka A, Mika P. Acta Bioeng Biomech. 2011;13(1):27-33.
High heel footwear may be destructive for the spine because of an increased erector spinae muscle bioelectrical activity and increased ground reaction forces affecting lower limbs and the spine. The aim of this study was to evaluate the changes of bioelectrical activity in cervical paraspinal muscle during gait in low and in high heel shoes in different age groups. In 31 women aged 20-25 years and in 15 women aged 45-55 years without neck pain, the bioelectrical activity of the cervical paraspinal muscle was assessed during gait on flat surface with natural speed in three conditions: without shoes, in low (4 cm) and in high (10 cm) heel shoes. Higher bioelectrical activity cervical paraspinal muscle was noted during gait in high heel shoes in comparison to gait without shoes. The changes were more pronounced in the group of subjects aged 45-55 years. The prolonged wearing of shoes with stiletto type heels by individuals without neck pain is not safe for their spine and may lead to chronic paraspinal muscle fatigue.
Wearing high heels alters walking kinematics and kinetics and can create potentially adverse effects on the body. Our purpose was to determine how heel height affects frontal plane joint moments at the hip, knee, and ankle, with a specific focus on the knee moment due to its importance in joint loading and knee osteoarthritis. 15 women completed overground walking using three different heel heights (1, 5, and 9cm) for fixed speed (1.3ms(-1)) and preferred speed conditions while kinematic and force platform data were collected concurrently. For both fixed and preferred speeds, peak internal knee abduction moment increased systematically as heel height increased (fixed: 0.46, 0.48, 0.55Nmkg(-1); preferred: 0.47, 0.49, 0.53Nmkg(-1)). Heel height effects on net frontal plane moments of the hip and ankle were similar to those for the knee; peak joint moments increased as heel height increased. The higher peak internal knee abduction moment with increasing heel height suggests greater medial loading at the knee. Kinetic changes at the ankle with increasing heel height may also contribute to larger medial loads at the knee. Overall, wearing high heels, particularly those with higher heel heights, may put individuals at greater risk for joint degeneration and developing medial compartment knee osteoarthritis.
The influence of heel height on lower extremity kinematics and leg muscle activity during gait in young and middle-aged women.
Mika A, Oleksy L, Mika P, Marchewka A, Clark BC. Gait Posture. 2012 Jan 31
The aim of this study was to evaluate the changes in electromyographic (EMG) activity of the lower limb muscles, and hip, knee and ankle kinematics during gait while wearing low- (4-cm) and high-heeled (10-cm) shoes in 31 young and 15 middle-aged adult women. We observed an increase in knee flexion and decrease in ankle eversion associated with elevated heel heights suggesting that compensatory mechanisms attenuating ground reaction forces may be compromised during gait with higher-heeled shoes. Additionally, we observed increased muscle activity during high-heeled gait that may exacerbate muscle fatigue. Collectively, these findings suggest that permanent wearing of heeled footwear could contribute to muscle overuse and repetitive strain injuries.
The influence of heel height on lower extremity kinematics and leg muscle activity during gait in young and middle-aged women.
Mika A, Oleksy L, Mika P, Marchewka A, Clark BC. Gait Posture. 2012 Jan 31
And the barefoot/minimalist running advocates get all worked up over traditional running shoes having a 10-13 mm heel height (about 1/4 to 1/3rd the amount of what these authors consider a "low heeled shoe")?!
If the barefoot/minimalist running advocates only would put as much energy into getting women to wear lower heeled shoes (less than 4 cm) as they do in worrying about a 1 cm heel height differential (i.e. heel drop) in traditional running shoes, then they actually may be doing something constructive, for a change, at preventing shoe-related injuries and deformity in people!
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
The Effect of Walking in High- and Low-Heeled Shoes on Erector Spinae Activity and Pelvis Kinematics During Gait.
Mika A, Oleksy L, Mika P, Marchewka A, Clark BC. Am J Phys Med Rehabil. 2012 Feb 2
Wearing high-heeled shoes may produce deleterious effects on the musculoskeletal system. The purpose of this study was to evaluate the changes in electromyographic (EMG) activity of the erector spinae muscles and pelvis kinematics during gait while wearing low- and high-heeled shoes in both young and middle-aged adult women.
In 31 young women (20-25 yrs) and 15 middle-aged women (45-55 yrs) without back pain, the EMG activity of the erector spinae muscle and pelvis kinematics in the sagittal, frontal, and transverse planes were assessed during gait on flat surface at natural speeds in three conditions: without shoes and in low- (4 cm) and high- (10 cm) heeled shoes.
In younger women, significant differences in lumbar erector spinae EMG activity were observed during gait at initial ground contact as well as in toe off between the three conditions, with an increasing amount of EMG activity being observed in association with increased heel height. In middle-aged women, significantly higher lumbar erector spinae EMG activity was noted during gait with high-heeled shoes compared with gait without shoes. Interestingly, younger women exhibited an increase in pelvic range of motion in the sagittal plane during high-heeled gait compared with low-heeled gait and walking without shows; however, this compensatory response was not observed in middle-aged women.
From a clinical perspective, increased lumbar erector spinae muscle activity associated with wearing high-heeled shoes could exacerbate muscle overuse and lead to low back problems. The lower pelvic range of motion associated with wearing high heels in middle-aged women may indicate that tissues in the lumbopelvic region become more rigid with age and that the harmful effect of high-heeled shoes on posture and spinal tissues may be more pronounced with advancing age.
Study on lumbar kinematics and the risk of low back disorder in female university students by using shoes of different heel heights.
Iqbal R, De A, Mishra W, Maulik S, Chandra A. Work. 2012 Jan 1;41(0):2521-6.
The study was taken up to investigate the effects of heel heights on lumbar kinematics and the risk of Low Back Disorder (LBD) in females. Nineteen female university students (24.5±3.36 yrs) volunteered in the study. Lumbar kinematics was measured by using Industrial Lumbar Motion Monitor (iLMM). The volunteers were asked to walk for a distance of 50 meters in 3 different given conditions i.e bare foot (Heel 0), with flat heels (Heel 1) and with high heels (Heel 2). Heights of Heel 1 and Heel 2 were 1.5±0.84 cm and 5.5±1.70 cm respectively. The Lumbar kinematic parameters studied were- Average Twisting Velocity (ATV), Maximum Sagital Flexion (MSF) and Maximum Lateral Velocity (MLV). It was observed that all the above mentioned Lumbar kinematics - ATV, MSF and MLV increases with increase of heel heights, which in turn increases the risk of LBD. As a result of increase in Lumbar kinematic values with increase in heel heights, LBD risk has also increased. Mean and SD of the LBD risk with Heel 0, Heel 1 and Heel 2 were 16.79±6.04%, 19.00±7.38% and 22.11±6.98% respectively. Lower stature with high heels showed higher risk of LBD than the higher stature with high heels
The influence of heel height on frontal plane ankle biomechanics: implications for lateral ankle sprains.
Foster A, Blanchette MG, Chou YC, Powers CM. Foot Ankle Int. 2012 Jan;33(1):64-9.
Wearing high heel shoes is thought to increase an individual's likelihood of experiencing a lateral ankle sprain. The purpose of this study was to evaluate the influence of heel height on frontal plane kinematics, kinetics, and electromyographic (EMG) activity of the ankle joint during walking.
Eighteen healthy women participated. Three-dimensional kinematics, ground reaction forces, and EMG signals of the tibialis anterior (TA) and peroneus longus (PL) were recorded as subjects ambulated in high (9.5~cm) and low (1.3~cm) heel shoes at a self-selected walking velocity. Peak ankle plantarflexion, peak ankle inversion angle, and the peak ankle inversion moment during the stance phase of gait were evaluated. The EMG variables of interest consisted of the normalized average signal amplitude of the TA and PL during the first 50% of the stance phase. Paired t-tests were used to assess differences between the two shoe conditions.
When compared to the low heel condition, wearing high heels resulted in significantly greater peak ankle plantarflexion and inversion angles (p < 0.001). In addition, the peak inversion moment and PL muscle activation was found to be significantly higher in the high heel condition (p < 0.001). No difference in TA muscle activity was found between shoe conditions (p = 0.30).
The plantarflexed and inverted posture when wearing high heels may increase an individual's risk for experiencing a lateral ankle sprain.
Data obtained from this investigation highlights the need for increased awareness and proper education related to the wearing of high heel shoes.
Walking on high heels changes muscle activity and the dynamics of human walking significantly.
Simonsen EB, Svendsen MB, Nørreslet A, Baldvinsson HK, Heilskov-Hansen T, Larsen PK, Alkjær T, Henriksen M. J Appl Biomech. 2012 Feb;28(1):20-8.
The aim of the study was to investigate the distribution of net joint moments in the lower extremities during walking on high-heeled shoes compared with barefooted walking at identical speed. Fourteen female subjects walked at 4 km/h across three force platforms while they were filmed by five digital video cameras operating at 50 frames/second. Both barefooted walking and walking on high-heeled shoes (heel height: 9 cm) were recorded. Net joint moments were calculated by 3D inverse dynamics. EMG was recorded from eight leg muscles. The knee extensor moment peak in the first half of the stance phase was doubled when walking on high heels. The knee joint angle showed that high-heeled walking caused the subjects to flex the knee joint significantly more in the first half of the stance phase. In the frontal plane a significant increase was observed in the knee joint abductor moment and the hip joint abductor moment. Several EMG parameters increased significantly when walking on high-heels. The results indicate a large increase in bone-on-bone forces in the knee joint directly caused by the increased knee joint extensor moment during high-heeled walking, which may explain the observed higher incidence of osteoarthritis in the knee joint in women as compared with men.
Movement Behavior of High-Heeled Walking: How Does the Nervous System Control the Ankle Joint during an Unstable Walking Condition?
Alkjær T, Raffalt P, Petersen NC, Simonsen EB. PLoS One. 2012;7(5):e37390.
The human locomotor system is flexible and enables humans to move without falling even under less than optimal conditions. Walking with high-heeled shoes constitutes an unstable condition and here we ask how the nervous system controls the ankle joint in this situation? We investigated the movement behavior of high-heeled and barefooted walking in eleven female subjects. The movement variability was quantified by calculation of approximate entropy (ApEn) in the ankle joint angle and the standard deviation (SD) of the stride time intervals. Electromyography (EMG) of the soleus (SO) and tibialis anterior (TA) muscles and the soleus Hoffmann (H-) reflex were measured at 4.0 km/h on a motor driven treadmill to reveal the underlying motor strategies in each walking condition. The ApEn of the ankle joint angle was significantly higher (p<0.01) during high-heeled (0.38±0.08) than during barefooted walking (0.28±0.07). During high-heeled walking, coactivation between the SO and TA muscles increased towards heel strike and the H-reflex was significantly increased in terminal swing by 40% (p<0.01). These observations show that high-heeled walking is characterized by a more complex and less predictable pattern than barefooted walking. Increased coactivation about the ankle joint together with increased excitability of the SO H-reflex in terminal swing phase indicates that the motor strategy was changed during high-heeled walking. Although, the participants were young, healthy and accustomed to high-heeled walking the results demonstrate that that walking on high-heels needs to be controlled differently from barefooted walking. We suggest that the higher variability reflects an adjusted neural strategy of the nervous system to control the ankle joint during high-heeled walking.
Control of the motion of the body's center of mass in relation to the center of pressure during high-heeled gait
Hui-Lien Chien, Tung-Wu Lu, Ming-Wei Liu Gait & Posture; Article in Press
High-heeled shoes are associated with instability and falling, leading to injuries such as fracture and ankle sprain. Knowledge of the motion of the body's center of mass (COM) with respect to the center of pressure (COP) during high-heeled gait may offer insights into the balance control strategies and provide a basis for approaches that minimize the risk of falling and associated adverse effects. The study aimed to investigate the influence of the base and height of the heels on the COM motion in terms of COM–COP inclination angles (IA) and the rate of change of IA (RCIA). Fifteen females who regularly wear high heels walked barefoot and with narrow-heeled shoes with three heel heights (3.9cm, 6.3cm and 7.3cm) while kinematic and ground reaction force data were measured and used to calculate the COM and COP, as well as the temporal-distance parameters. The reduced base of the heels was found to be the primary factor for the reduced normalized walking speed and the reduced frontal IA throughout the gait cycle. This was achieved mainly through the control of the RCIA during double-leg stance (DLS). The heel heights affected mainly the peak RCIA during DLS, which were not big enough to affect the IA. These results suggest young adults adopt a conservative strategy for balance control during narrow-heeled gait. The results will serve as baseline data for future evaluation of patients and/or older adults during narrow-heeled gait with the aim of reducing the risk of falling.
► Young adults adopt a conservative strategy for balance control during narrow-heeled gait.
► The reduced base but the height of the heels led to the reduced normalized walking speed.
► The reduced heel base was responsible for a reduced frontal COM–COP inclination angles.
► Control of the COM–COP motion during double-leg stance is critical for balance.
[Purpose] This study researched the effect of different types of shoe on the muscles surrounding the cervical spine, the thoracic spine and the lumbar spine by analyzing muscle activation of the paravertabral muscle during walking on flat ground.
[Subjects] The 28 subjects of this experiment were females in their 20s, with a foot size of 235–240 mm and a normal gait pattern, who had no foot deformities or muscle problems.
[Methods] We selected three kinds of shoes sized 240 mm, and measured the muscle activation of the paraspinal muscles around C4, T12 and L3, and the trapezius and multifidus muscle.
[Results] The muscle activations of all muscles differed significantly among the shoes. Especially, at the C4 paraspinal muscle and trapezius, the value of muscle activation induced by the flat shoes was the lower than those induced by the other shoes. The muscle activation induced by the functional walking shoes was significantly higher than that induced by the flat shoes at the C4 paraspinal muscle, and the muscle activations induced by the high-heel shoes were significantly higher than those induced by the other shoes in all of the muscles except for the L3 paraspinal muscle.
[Conclusion] In view of these results, wearing high-heel shoes is not recommended for those who have spinal problems, and those who have cervical troubles should be advised to wear only flat shoes.
Background: Women wearing high-heeled shoes often complain of foot instability and low-back pain. Previous studies have demonstrated that using total-contact inserts (TCIs) in running shoes reduces impact on leg muscles and alters rearfoot motion. This study investigated how shoe heel height and use of TCIs in high-heeled shoes affect the wearer's rearfoot complex, muscle loading, and subjective comfort.
Methods: Fifteen inexperienced high heel wearers walked under 6 test conditions formed by the cross-matching of shoe insert (with and without TCI) and heel height (1.0, 5.1, and 7.6 cm) at a speed of 1.3 m/s. The measures of interest were rearfoot kinematics; muscle activities by electromyography (EMG) of the tibialis anterior (TA), medial gastrocnemius (MG), quadriceps (QUA), hamstrings (HAM), and erector spinae (ES); and subjective comfort rating by visual analogue scale for each test condition.
Results: The statistical results showed that elevated heel height significantly increased plantar flexion (P < .001) and inversion (P < .01) at heel strike, prolonged TA-MG co-contraction (P < .001) and QUA activation period (P < .001), and increased root mean square (RMS) EMG in all measured muscles (TA, MG, QUA, ES: P < .001; HAM: P < .01). The use of TCIs reduced the rearfoot inversion angle (P < .01) and RMS EMG in both QUA and ES muscles (P < .01) and increased comfort rating (P < .001).
Conclusions: These findings suggest that wearing high-heeled shoes adversely affects muscle control and reduces loads in QUA and ES muscles.
Clinical Relevance: The use of a TCI may improve comfort rating and foot stability.