Effects of high heel wear and increased weight on the knee during walking

The impact of high-heel shoes on knee joint space width in healthy young females: A real-time ultrasound study

BACKGROUND

Wearing high heel shoes is thought to increase the risk of knee osteoarthritis in females by altering knee joint alignment and increasing muscle activation. However, direct measurements of knee joint space width using ultrasound have been limited. This study aimed to investigate the effects of 8-cm high-heel shoes on knee joint articular space in healthy young females during standing.

METHODS

A cross-sectional study was conducted with 30 healthy females (age 22 ± 1.3 years). Participants' knee medial, lateral and patellofemoral joint space width were measured using an ultrasound imaging device in both barefoot and high-heel shoes conditions. A general linear model was used to compare the impact of high-heel shoes on knee joint articular space with adjusted covariates of demographic and lower limb physical measurement data.

RESULTS

Significant reductions in lateral joint space width were observed in both the dominant and non-dominant knees when wearing high-heel shoes compared with barefoot (mean difference: dominant side = 1.63 ± 3.91 mm, non-dominant side = 2.34 ± 2.65 mm, P = 0.008). No significant changes were detected in medial and patellofemoral joint space width.

CONCLUSION

Wearing 8-cm high-heel shoes significantly reduces the lateral joint space width of the knee in healthy young females during standing, suggesting increased lateral knee joint stress. The current study underscores the importance of including standing as a test component when measuring joint space changes in future studies and clinical practice to comprehensively evaluate the effects of high-heel usage on knee joint biomechanics.

Development of Mobile Application Based on AI for Predicting the Suitable Height of High Heels

As high heels become increasingly popular in everyday attire, their impact on foot and lower limb health has garnered widespread attention. Wearing high heels of inappropriate height over a long period can cause damage to an individual's ankles, knees, and spine. This study developed a mobile application based on YOLOv8, aimed at providing users with personalized recommendations for the maximum height of high heels, thereby reducing the health risks associated with long-term wear of high heels. Compared to the previous generation system we developed, this generation's system simplifies the analytical process and has a lightweight model that has been ported to mobile devices, greatly enhancing usability and privacy. We validate and discuss the experimental results to confirm that our system has improved predictive capabilities. The error of the proposed system is only a mean absolute error of 0.76 cm. Users only need to record a video of their elevated heels and input it into the mobile application to measure the maximum height of high heels, thus minimizing the damage to lower limb health caused by high heels.

Gender as a social and structural variable: research perspectives from the National Institutes of Health (NIH)

Gender is a social and structural variable that encompasses multiple domains, each of which influences health: gender identity and expression, gender roles and norms, gendered power relations, and gender equality and equity. As such, gender has far-reaching impacts on health. Additional research is needed to continue delineating and untangling the effects of gender from the effects of sex and other biological variables. The National Institutes of Health (NIH) vision for women's health is a world in which the influence of sex and/or gender are integrated into the health research enterprise. However, much of the NIH-supported research on gender and health has, to date, been limited to a small number of conditions (e.g., HIV, mental health, pregnancy) and locations (e.g., sub-Saharan Africa; India). Opportunities exist to support transdisciplinary knowledge transfer and interdisciplinary knowledge building by advancing health-related social science research that incorporates best practices from disciplines that have well-established methods, theories, and frameworks for examining the health impacts of gender and other social, cultural, and structural variables.

Walking in high-heel shoes induces redistribution of joint power and work

Walking in high-heel shoes (HHS) decreases the push-off power and little research has examined the specific muscle groups that compensate for it. The purpose was to examine the effects of walking in HHS compared to barefoot on lower extremity net joint work and power. Fourteen young women walked in HHS and barefoot at a fixed speed of 1.3 m·s^-1. Marker position and ground reaction force data were synchronously measured at 100 and 1000 Hz, respectively. Peak power and joint work variables were computed over the power phases of the gait cycle using an inverse dynamic approach. When walking in HHS was compared to barefoot, participants exerted a diminished push-off characterized by lesser peak power and lesser work by the ankle plantar flexors in late stance (A2 phase; p < 0.001). To compensate for the reduced ankle plantar flexor power, greater peak power was generated and work was performed in early stance by hip extensors (H1 phase; p ≤ 0.001), in mid-stance by knee extensors (K2 phase; p < 0.001) and in late stance and early swing phase by hip flexor muscles (H3 phase; p ≤ 0.001). Walking in HHS induces biomechanical plasticity and causes distal-to-proximal redistribution of net joint power and work during walking.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Salient Targets and Fear of Falling Changed the Gait Pattern and Joint Kinematic of Older Adults

BACKGROUND

Fear of falling and environmental barriers in the home are two major factors that cause the incidence of falling. Poor visibility at night is one of the key environmental barriers that contribute to falls among older adult residents. Ensuring their visual perception of the surroundings, therefore, becomes vital to prevent falling injuries. However, there are limited works in the literature investigating the impact of the visibility of the target on older adults' walking destinations and how that impact differs across them with different levels of fear of falling.

OBJECTIVE

The purpose of the study was to examine the effects of target salience on older adults' walking performance and investigate whether older adults with varying levels of fear of falling behave differently.

METHODS

The salient target was constructed with LED strips around the destination of walking. Fifteen older adults (aged 75 years old and above), seven with low fear of falling and eight with high fear of falling, volunteered for the study. Participants walked from the designated origin (i.e., near their beds) to the destination (i.e., near the bathroom entrance), with the target turned on or off around the destination of the walking trials. Spatiotemporal gait variables and lower-body kinematics were recorded by inertial sensors and compared by using analysis of variance methods.

RESULTS

Data from inertial sensors showed that a more salient target at the destination increased older adults' gait speed and improved their walking stability. These changes were accompanied by less hip flexion at heel strikes and toe offs during walking. In addition, older adults with low fear of falling showed more substantial lower-body posture adjustments with the salient target presented in the environment.

CONCLUSIONS

Older adults with a low fear of falling can potentially benefit from a more salient target at their walking destination, whereas those with a high fear of falling were advised to implement a more straightforward falling intervention in their living areas.

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

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

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

BACKGROUND

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

RESEARCH QUESTION

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

METHODS

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

RESULTS

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

SIGNIFICANCE

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

Influences of high-heeled shoe parameters on gait cycle, center of pressure trajectory, and plantar pressure in young females during treadmill walking

PURPOSE

This study aimed to investigate the influences of high-heeled shoe (HHS) parameters on gait cycle, center of pressure (COP) trajectory, and plantar pressure in young females.

METHODS

Twenty healthy adult females were recruited to participate in this study. Subjects walked on a treadmill at a fixed speed (1 m/s). Overall, six pairs of HHSs were evaluated, presenting two heel types (thin and thick) and three different heel heights (low: 3 cm, medium: 6 cm, and high: 8.2 cm). Subjects also wore flat shoes (heel height: 0.2 cm) as the control group.

RESULTS

The gait cycle, COP parameters, peak pressure (PP), maximum force, contact area (CA), and force-time integral (impulse) were measured. The comparison between these parameters when the volunteers wore thick heel and flat shoes at different walking conditions indicated that thin heels caused a significant increase in the pre-swing parameter, CA, and PP of the first toe and first metatarsus. Increased heel heights yielded smaller gait line lengths, single support lines, and smaller hindfoot areas. By contrast, increased anterior-posterior positions and plantar pressure parameter values were noted for the forefoot.

CONCLUSIONS

Data analyses showed significant differences in the plantar pressure distribution associated with heel height and heel type at increased pressure in the first metatarsal and central forefoot region and decreased pressure in the midfoot and heel sections, thus increasing anterior shift. The results presented herein may allow for the design of HHSs with reduced adverse health effects on the wearer.

Heel pain in female patients with early knee osteoarthritis

Background

Multiple lower limb joint involvement is one of the most common and debilitating musculoskeletal conditions, while the complaints from both heel and knee pain are considered the most frequent. For that reason, in this cross-sectional study, the association between heel pain (HP) and early knee osteoarthritis (EKOA) was investigated; the most painful site and side of HP, the prevalence, and risk factors for disabling HP in patients with EKOA were identified.

Results

Bilateral HP (56%) and posterior HP (54%) were found to be the most prevalent complaints, and 66% of patients reported the HP to be non-disabling. There was a very high positive statistically significant correlation between the Manchester Foot Pain Disability Index (MFPDI) and both the Health Assessment Questionnaire (HAQ) and the total Western Ontario and McMaster University Osteoarthritis (WOMAC) score (p ≤ 0.001), while there was a high negative statistically significant correlation between MFPDI and quadriceps angle of the most affected knee (p = 0.002). A higher total WOMAC score (OR 1.077, 95% CI 1.014 to 1.145) significantly increases the risk of developing disabling HP, while wearing 2–3-cm heels during the past month was found to be protective against the development of disabling HP (odds ratio < 1).

Conclusion

Disabling HP was present in a third of patients with EKOA and HP, and it was associated with flat shoe wear as well as a high total WOMAC score. Also, it had a statistically significant correlation with varus knee mal-alignment. Furthermore, decreased functional ability in the presence of HP was found to lead to significant disability. Moreover, a striking finding in this study was the longer mean duration of HP compared to the duration of knee symptoms.

Using Sexual Selection Theories to Examine Contextual Variation in Heterosexual Women's Orientation Toward High Heels

High heels are symbols of female sexuality and are "costly signals" if the risks of wearing them are offset by improving women's attractiveness to men. From a functionalist perspective, the costs versus benefits of wearing heels may vary according to personal and contextual factors, such as her effectiveness at competing for mates, or at times when such motives are stronger. Here, we examined potential differences between women (self-rated attractiveness, dyadic versus solitary sexual desire, women's age, competitive attitudes toward other women) and contextual variation (priming mating and competitive motives) in their responses to high heels. Study 1 (N = 79) and Study 2 (N = 273) revealed that self-rated attractiveness was positively related to orientation toward heeled shoes. When examining responses to two very attractive shoes (one higher heel, one lower heel) in Study 2, dyadic sexual desire, but not solitary sexual desire or intrasexual competitiveness, predicted their inclination to buy the higher-heeled shoe. In Study 3 (N = 142), young women chose high heels when primed with free choice of a designer shoe (95% CI [53.02 mm, 67.37 mm]) and preferred a heel 22 mm (0.87") higher than older women (Study 4, N = 247). Contrary to predictions, priming mating or competitive motives did not alter women's preference toward a higher heel (Studies 3 and 4). Our studies suggest that attractive women augment their physical appeal via heels. High heels may be a subtle indicator of dyadic sexual desire, and preferences for heels are stronger at times in the lifespan when mating competition is relatively intense.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

Cross-sectional observational study.

SETTING

Tertiary care center.

PARTICIPANTS

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

MAIN OUTCOME MEASUREMENTS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

III.

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

BACKGROUND

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

RESEARCH QUESTION

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

METHODS

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

RESULTS

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

SIGNIFICANCE

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

Effects of high heeled shoes on gait. A review

BACKGROUND

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

RESEARCH QUESTION

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

METHODS

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

RESULTS

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

The relationship between foot and ankle symptoms and risk of developing knee osteoarthritis: data from the osteoarthritis initiative

OBJECTIVE

To investigate whether foot and/or ankle symptoms increase the risk of developing (1) knee symptoms and (2) symptomatic radiographic knee osteoarthritis (OA).

DESIGN

1020 Osteoarthritis Initiative (OAI) participants who were at-risk of knee OA, but were without knee symptoms or radiographic knee OA, were investigated. Participants indicated the presence and laterality of foot/ankle symptoms at baseline. The main outcome was development of knee symptoms (pain, aching or stiffness in and around the knee on most days of the month for at least 1 month in the past year). A secondary outcome was development of symptomatic radiographic knee OA (symptoms plus Kellgren and Lawrence [KL] grade ≥2), over the subsequent 4 years. Associations between foot/ankle symptoms and study outcomes were assessed by logistic regression models.

RESULTS

Foot/ankle symptoms in either or both feet significantly increased the odds of developing knee symptoms (adjusted odds ratio (OR) 1.55, 95% confidence interval (CI) 1.10 to 2.19), and developing symptomatic radiographic knee OA (adjusted OR 3.28, 95% CI 1.69 to 6.37). Based on laterality, contralateral foot/ankle symptoms were associated with developing both knee symptoms (adjusted OR 1.68, 95% CI 1.05 to 2.68) and symptomatic radiographic knee OA (adjusted OR 3.08, 95% CI 1.06 to 8.98), whilst bilateral foot/ankle symptoms were associated with developing symptomatic radiographic knee OA (adjusted OR 4.02, 95% CI 1.76 to 9.17).

CONCLUSION

In individuals at-risk of knee OA, the presence of contralateral foot/ankle symptoms in particular increases risk of developing both knee symptoms and symptomatic radiographic knee OA.

Effects of load carriage and footwear on lower extremity kinetics and kinematics during overground walking

Kinetic and kinematic responses during walking vary by footwear condition. Load carriage also influences gait patterns, but it is unclear how an external load influences barefoot walking. Twelve healthy adults (5 women, 7 men) with no known gait abnormalities participated in this study (age=23±3years, height=1.73±0.11m, and mass=70.90±12.67kg). Ground reaction forces and 3D motion were simultaneously collected during overground walking at 1.5ms^-1 in four conditions: Barefoot Unloaded, Shod Unloaded, Barefoot Loaded, and Shod Loaded. Barefoot walking reduced knee and hip joint ranges of motion, as well as stride length, stance time, swing time, and double support time. Load carriage increased stance and double support times. The 15% body weight load increased GRFs ∼15%. Walking barefoot reduced peak anteroposterior GRFs but not peak vertical GRFs. Load carriage increased hip, knee, and ankle joint moments and powers, while walking barefoot increased knee and hip moments and powers. Thus, spatiotemporal and kinematic adjustments to walking barefoot decrease GRFs but increase knee and hip kinetic measures during overground walking. The ankle seems to be less affected by these footwear conditions. Regardless of footwear, loading requires larger GRFs, joint loads, and joint powers.

Dance between biology, mechanics, and structure: A systems-based approach to developing osteoarthritis prevention strategies

Osteoarthritis (OA) is a leading cause of human suffering and disability for which disease-modifying treatments are lacking. OA occurs through complex and dynamic interplays between diverse factors over long periods of time. The traditional research and clinical focus on OA, the end stage disease, obscured understanding pathogenesis prior to reaching a common pathway defined by pain and functional deficits, joint deformity, and radiographic changes. To emphasize disease modification and prevention, we describe a multi-disciplinary systems-based approach encompassing biology, mechanics, and structure to define pre-osteoarthritic disease processes. Central to application of this model is the concept of "pre-osteoarthritis," conditions where clinical OA has not yet developed. Rather, joint homeostasis has been compromised and there are potentially reversible markers for heightened OA risk. Key messages from this perspective are (i) to focus research onto defining pre-OA through identifying and validating biological, mechanical, and imaging markers of OA risk, (ii) to emphasize multi-disciplinary approaches, and (iii) to propose that developing personalized interventions to address reversible markers of OA risk in healthy joints may be the key to prevention. Ultimately, a systems-based analysis of OA pathogenesis shows potential to transform clinical practice by facilitating development and testing of new strategies to prevent or delay the onset of osteoarthritis.