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

Health View to Decrease Negative Effect of High Heels Wearing: A Systemic Review Hindawi Applied Bionics and Biomechanics Volume 2021, Article ID 6618581, 10 pages https://doi.org/10.1155/2021/6618581 Review Article Health View to Decrease Negative Effect of High Heels Wearing: A Systemic Review 1,2 1 3 1 1 Meizi Wang, Ci Jiang , Gusztáv Fekete, Ee-Chon Teo, and Yaodong Gu Faculty of Sports Science, Ningbo University, Ningbo, China Faculty of Engineering, University of Pannonia, Veszprem, Hungary Savaria Institute of Technology, Eötvös Loránd University, Hungary Correspondence should be addressed to Ci Jiang; davidmaowl@gmail.com Received 20 October 2020; Revised 5 February 2021; Accepted 4 March 2021; Published 15 March 2021 Academic Editor: Donato Romano Copyright © 2021 Meizi Wang et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 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). 1. Introduction and medial gastrocnemius [12–14]. These above-mentioned disturbances have been identified as negative implications The potential impact of HH shoes on women’s health for for the human body. It is presumed that they contribute to several pathologies including metatarsalgia, hallux valgus, over 50 years has been of concern in medical circles. Studies Achilles tendon tightness, knee osteoarthritis (OA), plantar have shown that wearing HH can lead to slower self-selected fasciitis, and lower back pain, not to mention the elevated walking speed, shorter step length, and smaller stance phase instability and imbalance, which can result in a greater risk duration, while it increases ankle plantar flexion, knee plan- tar flexion, anterior pelvic tilt, and trunk extension [1–7]. of falling and slipping [15–19]. Despite widespread warnings from public health institu- Redistributing the plantar pressure, higher ground reaction forces (GRF), larger loading rate, higher peak knee external tions and international medical societies [20], there is still a large proportion of the population wearing HH in their daily adduction moments, and higher peak patellofemoral joint stress have been detected during walking in HH [8–11]. It life. Regarding why women choose to wear HH, Broega et al. is worthy to note that substantial bodily adjustments have surveyed 574 females, between the ages of 24 and 45, who indicated that beauty and femininity were the key drivers of been observed due to wearing HH, e.g., change in the neuro- muscular activation pattern, shortening of the gastrocnemius women’s behavior [21]. Therefore, accurate suggestions must muscle fascicle muscles, increase in the Achilles tendon stiff- be provided about how to counter the adverse effects of HH ness, and higher muscle activity of the soleus, tibialis anterior, using, instead of only giving a simple advice on not wearing 2 Applied Bionics and Biomechanics browse the full text. Then, if the full text failed to comply with it. Consequently, in the near future, the design of HH shoes must be associated to comfort and aesthetics in order to meet any of the eligibility criteria, it would be deleted. the requirements of beauty and health. 2.3. Data Extraction and Quality Assessment. The important Up to now, researchers have made significant efforts to details of the selected articles were extracted by two indepen- improve comfort of high-heeled shoes by suggesting a suitable dent reviewers (ECT and GF). The following data were heel height, an appropriate insert insole, sufficient support retrieved from the selected articles: author, year of publica- area of the heel, and even walking speed during HH gait. tion, participant characteristics, shoe condition, measured Studies have shown that an optimal range of height for main- variables, purpose, and main result. In case of disagreement taining postural balance and stability is between 3 and 5 cm [2, in data extraction, another reviewer (CJ) was included into 17, 18]. Yung and Wei observed that a TCI, coupled with a the discussion to reach a consensus. metatarsal pad, arch support, and heel-cup mechanism, redis- The principles of McMaster Critical Review Form were tributed the plantar pressure, and as a consequence, it conducted to thoroughly estimate methodological quality of decreased the impact force by 33.2% in the case of HH [22]. all selected studies [24–26]. This review form provided 15 It was also considered that small HBS increased the deviation separate elements to assess the various types of experimental of the center of pressure (COP), which on the one hand caused studies. A 2-point scoring system has been established, where larger foot pressure in the rearfoot region, and on the other the rating was defined as follows: “yes” (1 point), “no or not hand, it disturbed the muscle activity pattern [22]. measured,” or “not applicable” (0 point). This system can However, the effects of physiology and ergonomics on be utilized to appraise whether a study meets the standards HH design in terms of heel height, contact insole, and HBS for good methodological quality [26]. have not yet been summarized. It is essentially needed to reach a consensus for shoe manufacturers and users on what 3. Results kind of high-heeled shoes or insole is most optimal for women. Therefore, this systematic review is aimed at con- 3.1. Search Results and Validity. The bibliographical database cluding studies that have provided a specific way to effec- search identified 906 citations: 276 in PubMed, 243 in Sco- tively offset the negative effects of wearing HH in the case pus, 187 in Web of Science, and 200 in Embase. Duplicates of women. Our investigations included heel height, insole, were deleted leaving a total of 362 articles for evaluation. and HBS as parameters. 276 studies were eliminated since after scanning the titles and abstracts of the retrieved papers, it turned out that the 2. Materials and Methods content was inconsistent with the standards. 86 full-text studies were extracted for detailed review, and 78 studies 2.1. Design Data Sources, Search Strategy, and Study were removed as these failed to meet inclusion criteria. A Selection. This systemic review was carried out in accordance total of 8 studies were eventually eligible for all inclusion cri- with the PRISMA statement [23]. To identify relevant papers, teria. The detailed search strategy is shown in Figure 1, while a bibliographical search was conducted in four databases: the basic information of the selected articles is listed in Web of Science, PubMed, Scopus, and Embase. A manual Table 1. Quality evaluation of each article by the McMaster search was performed in OpenGrey literature in April 2020. score form is presented in Table 2. All of the extracted papers In some cases, YDG was responsible for contacting author were graded from moderate to high rating based on the by e-mail to obtain supplement information. The detailed McMaster critical appraisal tool. electronic search was as follows: “high heels”, “high-heeled shoes”, “women’s footwear”, “heel height”, “biomechanics”, 3.2. Overview of the Included Studies. An accurate recom- “comfort height”, “heel base size”, “kinematic parameters”, mendation for offsetting negative impact on HH for women “kinetic parameters”, “insole measurements”, and “insert”. is to alter three important parameters, namely, heel height, These keywords are combined and searched on each HBS, and sole insert. The biomechanical investigation of database. The first and second author (MWZ and CJ) inde- these parameters commonly involve kinematic, kinetic, and pendently performed relevance article screening, which perceived stability changes of the lower extremity,such as involved the title, abstract, full-text, and data extraction plantar pressure in a different region of the foot, COP devia- examination. tion in a gait cycle, spatiotemporal variation, and comfort rating. One included article contained EMG testing to detect 2.2. Eligibility Criteria. The eligibility of selecting papers was muscle activity in the tibialis anterior (TA), medial gastroc- estimated according to the following inclusion criteria: (1) nemius (MG), quadriceps (QUA), hamstrings (HAM), and the articles had to focus primarily on healthy women wearing erector spinae (ES) during walking, and one study recorded HH shoes, (2) the articles were published in English, (3) full- heart rate as a physiological variable. text, peer-reviewed, original scientific articles published in journals, (4) the presented data is associated with HH gait 3.2.1. Heel Height. Two studies conducted several experi- (including spatiotemporal, kinematic, kinetic parameters, ments to determine an appropriate height heel of high- and EMG), (5) the articles focused on how to alleviate harm- heeled shoes in order to reduce disturbance of the locomotor ful influences on female health with HH, and (6) the articles pattern. Based on three different walking speeds, Nadège had to be retrievable. If the abstract did not present sufficient et al. assessed the effect of nine pairs of heel height (0 cm, details for any of the eligibility criteria, the reviewers would 2 cm, 3 cm, 4 cm, 5 cm, 6 cm, 7 cm, 8 cm, 9 cm) on kinematic Applied Bionics and Biomechanics 3 Results of database search: 906 records (276 PubMed, 243 Scopus, 187 Web of Science, 200 Embase) 544 records aer duplicates removed 362 records screened 276 records excluded 78 records excluded with 86 full-articles assessed for eligibility improper inclusion criteria 8 articles included Figure 1: Flowchart of the search strategy. Table 1: Basic information on selected articles. Number [ref.] Author/date Title Journal Concentration Wearing high-heeled shoes during gait: 1 [27] Nadège et al. 2015 kinematics impact and determination American Journal of Life Sciences Heel height of comfort height The changes of COP and foot pressure 2 [28] Ko and Lee 2013 after one-hour walking wearing high-heeled Journal of Physical Therapy Science Heel height and flat shoes Effects of heel base size, walking speed, and slope angle on center of pressure 3 [30] Luximon et al. 2015 Human Movement Science HBS trajectory and plantar pressure when wearing high-heeled shoes Effect on plantar pressure distribution with Journal of Mechanics in Medicine 4 [29] Guo et al. 2012 wearing different base size of high-heel NBS and Biology shoes during walking and slow running Effect of shoe heel height and total-contact 5 [31] Hong et al. 2013 insert on muscle loading and foot stability Foot and Ankle Society Insert insole while walking Biomechanical effects of foam inserts on Journal of Mechanics in Medicine 6 [7] Li et al. 2010 forefoot load during the high-heeled gait: Insert insole and Biology a pilot study Influence of heel height and shoe insert on comfort perception and biomechanical 7 [8] Hong et al. 2005 Foot and Ankle International Insert insole performance of young female adults during walking Effects of shoe inserts and heel height on 8 [22] Yung and Wei 2005 foot pressure, impact force, and perceived Applied Ergonomics Insert insole comfort during walking parameters, in which the stride length (SL), swing phase walking for 1 hour in 0.5 cm, 4 cm, and 9 cm shoes, respec- (DSwp), duration of the stance phase (DStp), swing phase tively [28]. Results presented that 4 cm heel height is the most (DSwP), and gait ratio were included, as well as heart rate suitable, since this height is accompanied with stable COP [27]. The results indicated that the most comfortable heel tendency and less plantar pressure than walking in 0.5 cm or 9 cm shoes. Details are presented in Table 3. height is 4:13 ± 0:34 cm, which is accompanied with less dis- ruptive locomotor pattern and optimal heart rate, compared to other heights. Differently, Ko and Lee determined the most 3.2.2. HBS. Two studies were associated with the effect of comfortable heel height for HH shoes by detecting the dis- HBS on distribution of plantar pressure patterns, COP trajec- placement of the COP and plantar pressure change after tory, and perceived comfort. A large HBS demonstrated Included Eligibility Screening Identification 4 Applied Bionics and Biomechanics Table 2: Methodological quality of included studies by using the McMaster critical appraisal form. Study design Level Items Score Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1 CCT III-2 √√ √√√ √ x √ n/a √√ √√ x √ 12/14 2 CCT III-2 √√ √√√ x √√ n/a √√ √√ x √ 12/14 3 CCT III-2 √√ √√√ x √√ n/a √√ √√√√ 13/14 4 CCT III-2 √√ √√√ x √√ n/a √√ √√ x √ 12/14 5 CCT III-2 √√ √√√ x √√ n/a √√ √√ x √ 12/14 6 CCT III-2 √√ √√ xx √√ n/a √√ √√√√ 12/14 7 CCT III-2 √√ √√√ x √√ n/a √√ √√ x √ 12/14 8 CCT III-2 √√ √√√ x √√ n/a √√ √√ x √ 12/14 Level of evidence (based on NHMRC hierarchy); CCT: control clinical trial; FU/RCT: follow-up study from randomized control trial. √: yes; x: no/not reported; n/a: not applicable. McMaster Items: (1) study purpose clearly stated; (2) background literature reviewed; (3) appropriate research design; (4) sample described in detail; (5) sample size justified; (6) outcome measure reliability reported; (7) outcome measure validity reported; (8) intervention described; (9) contamination avoided; (10) cointervention avoided; (11) results reported in terms of statistical significance; (12) appropriate analysis method; (13) clinical significance reported; (14) dropouts reported; (15) appropriate conclusion. smaller maximal peak pear pressure in the rearfoot, midfoot, tion [7, 22, 32, 33]. The effect of four different types of foam and forefoot compared to small HBS [29, 30]. It must be insoles (soft 5 mm, soft 10 mm, hard 5 mm, hard 100 mm) in noted that the scale of HBS affects the COP location in the the targeted MF region on plantar pressure was tested. There anterior-posterior direction at the end of the stance phase. was a great advantage in soft 5 mm to reduce peak pressure The COP deviations are increased with a small HBS when by 26%, impact force by 27% in MF region compared to the compared to a large HBS [30]. Only one study reported infor- noninsert condition [7]. All the above insole types are pre- mation about the stability as a function of HBS. It can be con- sented in Figure 2(a). More details on female insert insoles cluded that a large HBS can lead to a more stable gait during are presents in Table 5. walking with HH [30]. Details are presented in Table 4, and different sizes of HBS are shown in Figure 2(b). 4. Discussion 3.2.3. Insert Insole. Four included studies evaluated the effect To reach a full understanding of how the design factors of of insert insole on kinematic, kinetic, EMG, and comfort rat- high-heeled shoes affect locomotor pattern, disturbance of ing of the lower extremity, but different types of insole were plantar pressure, and perceived comfort is crucial. This used for each study. One study investigated how subject’s review identified 8 articles, which appraised either the effect rearfoot kinematic, muscle activity, and subjective comfort of heel height, HBS, or insert insole on lower limb kinematic, were affected by TCI which were designed from rearfoot to kinetic, or EMG during waking with HH, as well as perceived metatarsal head during walking with HH (Figure 2(b) [31]. comfort. When compared with a noninsert condition, results showed that the use of a TCI could reduce peak MG by 19.0% and 4.1. Heel Height Studies. There are only two studies that eval- peak ES by 21.5% in HH with 7.6 cm, and rearfoot inversion uated the comfort heel height of HH by using different angle was significantly decreased. But this study did not pres- methods, and a consensus has been formed that shows that ent kinetic variation of the foot. Another included article the appropriate heel height in high-heeled shoes is 4:13 ± used an insole from the rearfoot to metatarsal head (TCI II) 0:34 cm [27, 28]. In addition, this result is also consistent that was designed by the orthotist to fit each participants’ foot with Ko who reported that the preferable heel height was to determine the effect of shoe inserts on plantar pressure, between 3 cm and 5 cm, but this article as a conference paper GRF, and perceived comfort during walking in different heel failed to be selected in this review [34]. A growing number of height shoes (1.0 cm, 5.1 cm, 7.6 cm) (Figure 2(b)) [8]. researches indicate that musculoskeletal systems are directly Results showed that the peak pressure of the medial forefoot modified from wearing HH. On the other hand, the human reduced by using TCL compared with noninsert shoes, and it foot naturally presents a moderate imbalance in body weight was more effective to use TCI in the higher heels than lower (BW) distribution; i.e., 43% of BW is loaded to the foot and flat heels. Furthermore, Yung and Wei also found that a front, with the remaining 57% at the heel portion when TCI decreased heel pressure by 25%, medial forefoot pressure walking barefoot. For that reason, a slight heel height shoe by 24%, and impact force by 33% [22]. (2 cm) is recommended to be used by orthopedic specialists, While the heel cup pad could decrease the heel pressure since it can balance the distribution of plantar pressure to and impact force and the use of single arch support inserts relieve rearfoot load [21]. But these outcomes depend on can attenuate the medial forefoot pressure, no special short-term testing rather than for a long period. Therefore, changes to the metatarsal pad using measured parameters the results of a suitable heel height in included articles may were found [22]. The medial forefoot (MF) has been consid- not predict the impact of wearing high-heeled shoes in the ered the most sensitive area in response to heel height varia- long term. Applied Bionics and Biomechanics 5 Table 3: Summary of articles related to the effect of appropriate heel height among females. Participant characteristics Walking Shoe condition Number (mean ± standard deviation) speed Variables measured Purpose Main findings N Age (years) Height (m) Weight (kg) HBS (cm ) Height of heel (cm) (cm/s) (i) SL (ii) DStP 0% Ffcwh To determine the (i) The comfort heel height was 22:40 ± 2:56 1:63 ± 0:04 59:07 ± 5:15 115 5.3 0, 2, 3, 4, 5, 6, 7, 8, 9 +20% Ffcwh (iii) DSwP comfort heel height for 4:13 cm ± 0:34 -20% Ffcwh the shoe (iv) Gait ratio (v) Heart rate (i) The distribution of foot pressure and COP did not change (i) Foot pressure To determine the most significantly in 4 cm heel height 215 20:90 ± 1:30 1:60 ± 3:30 52:10 ± 5:0 — 0.5, 4, 9 1.17 appropriate height for after walking shoe heels (ii) 4 cm heel height was (ii) COP preferable for health and comfort Note: Ffcwh: step frequency freely chosen in shoes without heel; SL: stride length; DStP: duration of the stance phase; DSwP: swing phase; COP: central of pressure. 6 Applied Bionics and Biomechanics Table 4: Summary of articles related to the effect of HBS on female. Participant characteristics Shoe condition (mean ± standard deviation) Walking Number Variables measured Purpose Main findings Height of speed (cm/s) N Age (years) Height (m) Weight (kg) HBS (cm2) heel (cm) (i) Smaller COP deviations in (i) COP larger HBS (ii) The walking speed mainly (ii) Perceived affected stability the locations of the COP in the Evaluated the effects of the anteroposterior direction during gait 315 22:50 ± 4:70 1:61 ± 0:04 51:30 ± 4:90 -0.88, -8.92 3 112, 143 HBS of HH shoes (iii) A maximal peak pressure increased over the forefoot, midfoot, (iii) Plantar and rearfoot in larger HBS pressure (iv) The participants felt more stable in larger HBS (i) Smaller plantar pressure in medial, Be better to select one with 22:0±0:81:60 ± 3:30 52:10 ± 5:0 413 -1.44, -7.7 7.8 100, 115, 200 (i) Plantar pressure central, and lateral of forefoot and toe a wide-based heel regions in larger HBS Note: COP: central of pressure; HBS: heel base support; HH: high heels. Applied Bionics and Biomechanics 7 Medial forefoot pad Metatarsal pad Total contact insert Arch support pad Heel cup pad Total contact insert II (a) (b) Figure 2: (a) The different insert pads mentioned in included studies. (b) The total contact insert, total contact insert II (from rearfoot to metatarsal head), and small and large heel base size mentioned in included studies. Note: (a) and (b) do not represent the actual ones used in the included study. 4.2. HBS Studies. The scale of HBS is another important fac- [22]. An arch support insole decreased peak pressure by tor influencing locomotor pattern during gait with HH. The 15% in the medial forefoot region and raised the pressure by 125.6% in the midfoot region, since it was used to prevent narrow heels are the most commonly used design in HH which increase plantar pressure, especially in the heel region depression of the longitudinal arch during weight bearing, and lead to instability [22, 35, 36]. Luximon et al. noted that thereby alleviating the tension of the plantar aponeurosis the maximal peak pressure uniformly increased over the [22, 41, 42]. Weight bearing can be transferred from the fore- whole plantar in large HBS, whereas a narrowed HBS pre- foot to the longitudinal and metatarsal arches by the metatar- sented higher maximal peak pressure in the toe region [30]. sal pad; however, no changes in pressure and impact forces This result is partially similar to Guo et al. whose research were found in the medial forefoot region reported by Yung showed that the plantar pressure of hallux was significantly and Wei [22]. Furthermore, medial forefoot pads with differ- increased in small HBS compared to large HBS [29]. Except ent foam hardness and thickness were utilized; and the for the impact of heel height, the narrow HBS may be a direct results showed that the thick soft pad can effectively reduce reason contributing to hammer toe which is caused by exces- larger pressure and impact force caused by HH in the medial sive pressure on the metatarsal-phalangeal region during forefoot when compared to other types [7, 43]. walking with HH. Additionally, a smaller HBS presented a In terms of using TCI, three included studies indicated that TCI relieved pressure and impact force on multiple areas larger COP deviation which triggered gait instability, where the toes had to grip the sole of shoes to keep stable. This of the foot simultaneously and significantly improved per- scenario may be another reason that could lead to the devel- ceived comfort during walking with HH [8, 22, 31]. The opment of a hammer toe when wearing HH [30]. TCI provides a highly conforming fit between the foot and It must be noted that only one heel height was used to the contact surface of the insole, as well as spreading and redistributing pressure over the rearfoot, midfoot, and fore- measure the function of using different HBS in two selected studies. Although previous researchers suggested that a foot. Notably, the current research notes that the use of TCI decreased HBS rather than an increased heel height was the is the most effective way to attenuate pressure in comparison main element for reducing stability during walking with to other single pads during walking with HH. Further studies HH [37], the different sizes of HBS combined with diverse are needed to evaluate the effect of different thicknesses and material properties of TCI on load and pressure redistribu- heel height should be assessed in the future to further con- firm the effectiveness of HBS on gait stabilization. tion during walking with HH shoes. What is more, the effec- tiveness of insoles also needs to be estimated in the long term 4.3. Insert Insole Studies. Insert insole has been widely used in to determine whether this type of intervention should be footwear to improve perceived comfort, absorbing energy recommended for women with high heels-related foot problems. attenuating impact forces, redistribute the plantar pressure, and reduce the risk of movement-related injury [38–40]. The various insert designs presented different kinetic modifi- 4.4. Limitations and Future Direction. The most obvious lim- cations during walking with HH. For instance, Yung and Wei itation in this review is the small sample size. Only 8 studies indicated that a heel cup pad reduced pressure by 24.3% and met our inclusion criteria hence the reason why a meta- analysis was not conducted. In addition, the effects of impact force by 18.6% in the heel region when wearing HH 8 Applied Bionics and Biomechanics Table 5: Summary of articles related to the effect of insert insole on female. Participant characteristics Shoe condition Number (mean ± standard deviation) Type of insole Variables measured Purpose Main findings N Age (years) Height (m) Weight (kg) Height of heel (cm) To investigate how shoe heel (i) The use of TCI reduced the (i) TCI II (from (i) Kinematic height and use of TCI in rearfoot inversion angle and in 24:5±4:5 159:3± 6:549:6± 6:4 515 1.0, 5.1, 7.6 rearfoot to (ii) EMG high-heeled shoes affect the wearer’s both QUA and ES muscles activity metatarsal head) (iii) Comfort rating rearfoot complex, muscle loading, (ii) Comfort rating increased by and subjective comfort using TCI (i) Thicker soft foam sole significantly (i) MF foams insole To determine the effect of foam reduced peak pressure in MF than with soft (5 mm), inserts in targeted medial foot thinner hard foams 22:0±2:0 163:0± 3:051:0± 4:5 68 0, 4.5, 8.5 (ii) MF soft 10 mm (i) Plantar pressure region on the foot pressure (ii) The maximum force and peak (iii) MF hard 5 mm distribution during normal pressure reduced in the MF region (iv) MF soft 10 mm walking bu using foams than no insole in HH (i) The comfort ratings were significantly increased when wearing with TCI (i) Perceived (ii) Use of the TCI reduced the To evaluate the effect of TCI stability peak pressure in the medial forefoot 720 25:4±3:8 157:8± 5:050:5± 4:2 1.0, 5.1, 7.6 (i) TCI insole on comfort perception and (ii) Plantar pressure (iii) Mean GRF decreased to 39% BW plantar pressure (iii) GRF in the highest shoes with the TCI (iv) It was more effective to use TCL in higher heels than in the lower heels and in flat heels (i) Heel cup insert reduced the heel pressure and impact force (ii) Arch support insert reduced (i) Heel cup pad Whether use of shoe inserts the medial forefoot pressure and (ii) Arch support (i) Plantar pressure change foot pressure distribution, 23 ± 3:4 160 ± 3 50 ± 3 810 1.0, 5.1, 7.6 improved comfort (iii) Metatarsal pad (ii) Comfort rating impact force, and perceived (iii) TCI reduce heel pressure, (iv) TCI comfort during walking medial forefoot pressure, and impact force and provided a higher perceived comfort Note: TCI: total contact insert; MF: medial forefoot; GRF: grand reaction force; BW: body weight; QUA: quadriceps; ES: erector spinae; EMG: electromyography. Applied Bionics and Biomechanics 9 walking/running speed on locomotor pattern during high- [2] M. Esenyel, K. Walsh, J. G. Walden, and A. Gitter, “Kinetics of high-heeled gait,” Journal of the American Podiatric Medical heeled gait were not studied because there are a wide range Association, vol. 93, no. 1, pp. 27–32, 2003. of variables and different experimental conditions that would [3] D. D. Barkema, T. R. Derrick, and P. E. Martin, “Heel height need to be taken into consideration. affects lower extremity frontal plane joint moments during It is worth thinking about HH in relation to finite ele- walking,” Gait & Posture, vol. 35, no. 3, pp. 483–488, 2012. ment model analysis and laboratory tests to determine what [4] N. J. Cronin, R. S. Barrett, and C. P. Carty, “Long-term use of kind of material properties, hardness, and thickness of insert high-heeled shoes alters the neuromechanics of human walk- insole are optimal to minimize the negative impacts of wear- ing,” Journal of Applied Physiology, vol. 112, no. 6, pp. 1054– ing HH. On the other hand, the age, height, and body mass 1058, 2012. are important parameters in wearing HH; the age affects [5] C. M. Lee, E. H. Jeong, and A. Freivalds, “Biomechanical effects muscle strength, the height may affect joint moment, and of wearing high-heeled shoes,” International Journal of Indus- bodyweight directly related to load increase. Future studies trial Ergonomics, vol. 28, no. 6, pp. 321–326, 2001. should be aimed at providing personal recommendations [6] M. G. Blanchette, J. R. Brault, and C. M. Powers, “The influ- for HH in terms of choosing the heel height and HBS size ence of heel height on utilized coefficient of friction during based on the individual characteristics that involve weight, walking,” Gait & Posture, vol. 34, no. 1, pp. 107–110, 2011. height, and age. It seems likely achieved by conducting a [7] J. S. Li, Y. D. Gu, X. J. Ren, M. J. Lake, and Y. J. Zeng, “Biome- comprehensive study that combines the numerical simula- chanical effects of foam inserts on forefoot load during the tion, finite element model analysis, and a large number of high-heeled gait: a pilot study,” Journal of Mechanics in Medi- sample experiments in the long term. cine and Biology, vol. 10, no. 4, pp. 667–674, 2012. [8] W. H. Hong, Y. H. Lee, H. C. Chen, Y. C. Pei, and C. Y. Wu, 5. Conclusions “Influence of heel height and shoe insert on comfort percep- tion and biomechanical performance of young female adults We have systematically reviewed studies focused on factors during walking,” Foot & Ankle International, vol. 26, no. 12, that aim to counter the adverse impacts on high-heeled pp. 1042–1048, 2005. shoes. The effects of heel height, heel base size, and insert [9] D. C. Kerrigan, J. L. Lelas, and M. E. Karvosky, “Women's insole on the biomechanical of lower extremity and perceived shoes and knee osteoarthritis,” The Lancet, vol. 357, comfort are concluded. Some evidence demonstrates that (i) no. 9262, pp. 1097-1098, 2001. the range of appropriate heel height for wearing HH is [10] J. C. Menant, S. D. Perry, J. R. Steele, H. B. Menz, B. J. Munro, 3.76 cm to 4.47 cm; (ii) compared to small heel base size, and S. R. Lord, “Effects of shoe characteristics on dynamic sta- the larger ones effectively increase gait stability, reduce risk bility when walking on even and uneven surfaces in young and of ankle injury, and improve comfort rating during walking older people,” Archives of Physical Medicine and Rehabilita- tion, vol. 89, no. 10, pp. 1970–1976, 2008. with HH; and (iii) the use of a total contact insert signifi- cantly decreases plantar pressure and impact forces on the [11] E. B. Simonsen, M. B. Svendsen, A. Nørreslet et al., “Walking on high heels changes muscle activity and the dynamics of foot so that a higher perceived comfort is achieved. However, human walking significantly,” Journal of Applied Biomechan- there were some limitations in the data presented in the ics, vol. 28, no. 1, pp. 20–28, 2012. included articles due to the different methodologies used [12] R. Csapo, C. N. Maganaris, O. R. Seynnes, and M. V. Narici, and a limited number of studies. All the above conclusions “On muscle, tendon and high heels,” Journal of Experimental need to be further tested in a longer duration experiment. Biology, vol. 213, no. 15, pp. 2582–2588, 2010. In the future, numerical simulation, finite element model [13] A. Mika, Ł. Oleksy, P. Mika, A. Marchewka, and B. C. Clark, analysis, and a large number of sample experiments should “The influence of heel height on lower extremity kinematics be combined to offer personal recommendations for wearing and leg muscle activity during gait in young and middle- HH based on the individuals’ characteristics. aged women,” Gait & Posture, vol. 35, no. 4, pp. 677–680, Conflicts of Interest [14] D. J. Stefanyshyn, B. M. Nigg, V. Fisher, B. O'Flynn, and W. Liu, “The influence of high heeled shoes on kinematics, The authors declare that they have no conflicts of interest. kinetics, and muscle EMG of normal female gait,” Journal of Applied Biomechanics, vol. 16, no. 3, pp. 309–319, 2000. Acknowledgments [15] M. R. Titchenal, J. L. Asay, J. Favre, T. P. Andriacchi, and C. R. Chu, “Effects of high heel wear and increased weight on the This study was sponsored by the by National Natural Science knee during walking,” Journal of Orthopaedic Research, Foundation of China (No. 81772423) and K. C. Wong Magna vol. 33, no. 3, pp. 405–411, 2015. Fund in Ningbo University. [16] J. Yu, D. W.-C. Wong, H. Zhang, Z.-P. Luo, and M. Zhang, “The influence of high-heeled shoes on strain and tension force of the anterior talofibular ligament and plantar fascia References during balanced standing and walking,” Medical Engineering & Physics, vol. 38, no. 10, pp. 1152–1156, 2016. [1] C. J. Ebbeling, J. Hamill, and J. A. Crussemeyer, “Lower extremity mechanics and energy cost of walking in high- [17] M. Wang, Y. Gu, and J. S. Baker, “Analysis of foot kinematics heeled shoes,” Journal of Orthopaedic & Sports Physical Ther- wearing high heels using the Oxford foot model,” Technology apy, vol. 19, no. 4, pp. 190–196, 1994. and Health Care, vol. 26, no. 5, pp. 815–823, 2018. 10 Applied Bionics and Biomechanics [34] P. H. Ko, T. Y. Hsiao, J. H. Kang, T. G. Wang, Y. W. Shau, and [18] M. Wang, Z. Yan, G. Fekete, J. S. Baker, and Y. Gu, “The kine- matics of the spine and lower limbs on sagittal plane in high- C. L. Wang, “Relationship between plantar pressure and soft heeled gait,” Journal of Medical Imaging and Health Informat- tissue strain under metatarsal heads with different heel ics., vol. 8, no. 5, pp. 973–978, 2018. heights,” Foot & Ankle International, vol. 30, no. 11, pp. 1111–1116, 2009. [19] Y. Zhang, M. Wang, J. Awrejcewicz, G. Fekete, F. Ren, and Y. Gu, “Using gold-standard gait analysis methods to assess [35] H. B. Menz and M. E. Morris, “Footwear characteristics and experience effects on lower-limb mechanics during moderate foot problems in older people,” Gerontology, vol. 51, no. 5, high-heeled jogging and running,” Journal of Visualized pp. 346–351, 2005. Experiments, vol. 127, pp. 1–7, 2017. [36] W. W. Shen, J. B. Ma, J. S. Li, and Y. D. Gu, “Study on plantar [20] American Podiatric Medical Association, Public opinion pressure during tilt walking in young group,” Journal of Con- research on foot health and care, APMA, USA, 2014. vergence Information Technology, vol. 8, no. 2, pp. 711–717, [21] A. C. Broega, M. Righetto, and R. Ribeiro, “Female high heel shoes: a study of comfort,” IOP Conference Series: Materials [37] H. L. Chien, T. W. Lu, and M. W. Liu, “Control of the motion Science and Engineering, vol. 254, no. 23, pp. 23–27, 2017. of the body's center of mass in relation to the center of pressure during high-heeled gait,” Gait & Posture, vol. 38, no. 3, [22] H. L. Yung and H. H. Wei, “Effects of shoe inserts and heel pp. 391–396, 2013. height on foot pressure, impact force, and perceived comfort during walking,” Applied Ergonomics, vol. 36, no. 3, pp. 355– [38] R. C. Dinato, A. P. Ribeiro, M. K. Butugan, I. L. R. Pereira, 362, 2005. A. N. Onodera, and I. C. N. Sacco, “Biomechanical variables and perception of comfort in running shoes with different [23] D. Moher, A. Liberati, J. Tetzlaff, and D. G. Altman, “Preferred reporting items for systematic reviews and meta-analyses: the cushioning technologies,” Journal of Science and Medicine in Sport, vol. 18, no. 1, pp. 93–97, 2015. PRISMA statement,” Annals of Internal Medicine, vol. 151, no. 4, pp. 264–9, W64, 2009. [39] Y. Urabe, N. Maeda, S. Kato, H. Shinohara, and J. Sasadai, [24] M. Law, D. Steward, N. Pollock, L. Letts, J. Bosch, and “Effect of shoe insole for prevention and treatment of lower M. 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Cavanagh, “Structural and functional pre- dictors of regional peak pressures under the foot during walk- ing,” Journal of Biomechanics, vol. 32, no. 4, pp. 359–370, 1999. [33] C. M. Speksnijder, R. J. Munckhof, S. A. Moonen, and G. H. Walenkamp, “The higher the heel the higher the forefoot- pressure in ten healthy women,” The Foot, vol. 15, no. 1, pp. 17–21, 2005. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Applied Bionics and Biomechanics Hindawi Publishing Corporation

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

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Hindawi Applied Bionics and Biomechanics Volume 2021, Article ID 6618581, 10 pages https://doi.org/10.1155/2021/6618581 Review Article Health View to Decrease Negative Effect of High Heels Wearing: A Systemic Review 1,2 1 3 1 1 Meizi Wang, Ci Jiang , Gusztáv Fekete, Ee-Chon Teo, and Yaodong Gu Faculty of Sports Science, Ningbo University, Ningbo, China Faculty of Engineering, University of Pannonia, Veszprem, Hungary Savaria Institute of Technology, Eötvös Loránd University, Hungary Correspondence should be addressed to Ci Jiang; davidmaowl@gmail.com Received 20 October 2020; Revised 5 February 2021; Accepted 4 March 2021; Published 15 March 2021 Academic Editor: Donato Romano Copyright © 2021 Meizi Wang et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 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). 1. Introduction and medial gastrocnemius [12–14]. These above-mentioned disturbances have been identified as negative implications The potential impact of HH shoes on women’s health for for the human body. It is presumed that they contribute to several pathologies including metatarsalgia, hallux valgus, over 50 years has been of concern in medical circles. Studies Achilles tendon tightness, knee osteoarthritis (OA), plantar have shown that wearing HH can lead to slower self-selected fasciitis, and lower back pain, not to mention the elevated walking speed, shorter step length, and smaller stance phase instability and imbalance, which can result in a greater risk duration, while it increases ankle plantar flexion, knee plan- tar flexion, anterior pelvic tilt, and trunk extension [1–7]. of falling and slipping [15–19]. Despite widespread warnings from public health institu- Redistributing the plantar pressure, higher ground reaction forces (GRF), larger loading rate, higher peak knee external tions and international medical societies [20], there is still a large proportion of the population wearing HH in their daily adduction moments, and higher peak patellofemoral joint stress have been detected during walking in HH [8–11]. It life. Regarding why women choose to wear HH, Broega et al. is worthy to note that substantial bodily adjustments have surveyed 574 females, between the ages of 24 and 45, who indicated that beauty and femininity were the key drivers of been observed due to wearing HH, e.g., change in the neuro- muscular activation pattern, shortening of the gastrocnemius women’s behavior [21]. Therefore, accurate suggestions must muscle fascicle muscles, increase in the Achilles tendon stiff- be provided about how to counter the adverse effects of HH ness, and higher muscle activity of the soleus, tibialis anterior, using, instead of only giving a simple advice on not wearing 2 Applied Bionics and Biomechanics browse the full text. Then, if the full text failed to comply with it. Consequently, in the near future, the design of HH shoes must be associated to comfort and aesthetics in order to meet any of the eligibility criteria, it would be deleted. the requirements of beauty and health. 2.3. Data Extraction and Quality Assessment. The important Up to now, researchers have made significant efforts to details of the selected articles were extracted by two indepen- improve comfort of high-heeled shoes by suggesting a suitable dent reviewers (ECT and GF). The following data were heel height, an appropriate insert insole, sufficient support retrieved from the selected articles: author, year of publica- area of the heel, and even walking speed during HH gait. tion, participant characteristics, shoe condition, measured Studies have shown that an optimal range of height for main- variables, purpose, and main result. In case of disagreement taining postural balance and stability is between 3 and 5 cm [2, in data extraction, another reviewer (CJ) was included into 17, 18]. Yung and Wei observed that a TCI, coupled with a the discussion to reach a consensus. metatarsal pad, arch support, and heel-cup mechanism, redis- The principles of McMaster Critical Review Form were tributed the plantar pressure, and as a consequence, it conducted to thoroughly estimate methodological quality of decreased the impact force by 33.2% in the case of HH [22]. all selected studies [24–26]. This review form provided 15 It was also considered that small HBS increased the deviation separate elements to assess the various types of experimental of the center of pressure (COP), which on the one hand caused studies. A 2-point scoring system has been established, where larger foot pressure in the rearfoot region, and on the other the rating was defined as follows: “yes” (1 point), “no or not hand, it disturbed the muscle activity pattern [22]. measured,” or “not applicable” (0 point). This system can However, the effects of physiology and ergonomics on be utilized to appraise whether a study meets the standards HH design in terms of heel height, contact insole, and HBS for good methodological quality [26]. have not yet been summarized. It is essentially needed to reach a consensus for shoe manufacturers and users on what 3. Results kind of high-heeled shoes or insole is most optimal for women. Therefore, this systematic review is aimed at con- 3.1. Search Results and Validity. The bibliographical database cluding studies that have provided a specific way to effec- search identified 906 citations: 276 in PubMed, 243 in Sco- tively offset the negative effects of wearing HH in the case pus, 187 in Web of Science, and 200 in Embase. Duplicates of women. Our investigations included heel height, insole, were deleted leaving a total of 362 articles for evaluation. and HBS as parameters. 276 studies were eliminated since after scanning the titles and abstracts of the retrieved papers, it turned out that the 2. Materials and Methods content was inconsistent with the standards. 86 full-text studies were extracted for detailed review, and 78 studies 2.1. Design Data Sources, Search Strategy, and Study were removed as these failed to meet inclusion criteria. A Selection. This systemic review was carried out in accordance total of 8 studies were eventually eligible for all inclusion cri- with the PRISMA statement [23]. To identify relevant papers, teria. The detailed search strategy is shown in Figure 1, while a bibliographical search was conducted in four databases: the basic information of the selected articles is listed in Web of Science, PubMed, Scopus, and Embase. A manual Table 1. Quality evaluation of each article by the McMaster search was performed in OpenGrey literature in April 2020. score form is presented in Table 2. All of the extracted papers In some cases, YDG was responsible for contacting author were graded from moderate to high rating based on the by e-mail to obtain supplement information. The detailed McMaster critical appraisal tool. electronic search was as follows: “high heels”, “high-heeled shoes”, “women’s footwear”, “heel height”, “biomechanics”, 3.2. Overview of the Included Studies. An accurate recom- “comfort height”, “heel base size”, “kinematic parameters”, mendation for offsetting negative impact on HH for women “kinetic parameters”, “insole measurements”, and “insert”. is to alter three important parameters, namely, heel height, These keywords are combined and searched on each HBS, and sole insert. The biomechanical investigation of database. The first and second author (MWZ and CJ) inde- these parameters commonly involve kinematic, kinetic, and pendently performed relevance article screening, which perceived stability changes of the lower extremity,such as involved the title, abstract, full-text, and data extraction plantar pressure in a different region of the foot, COP devia- examination. tion in a gait cycle, spatiotemporal variation, and comfort rating. One included article contained EMG testing to detect 2.2. Eligibility Criteria. The eligibility of selecting papers was muscle activity in the tibialis anterior (TA), medial gastroc- estimated according to the following inclusion criteria: (1) nemius (MG), quadriceps (QUA), hamstrings (HAM), and the articles had to focus primarily on healthy women wearing erector spinae (ES) during walking, and one study recorded HH shoes, (2) the articles were published in English, (3) full- heart rate as a physiological variable. text, peer-reviewed, original scientific articles published in journals, (4) the presented data is associated with HH gait 3.2.1. Heel Height. Two studies conducted several experi- (including spatiotemporal, kinematic, kinetic parameters, ments to determine an appropriate height heel of high- and EMG), (5) the articles focused on how to alleviate harm- heeled shoes in order to reduce disturbance of the locomotor ful influences on female health with HH, and (6) the articles pattern. Based on three different walking speeds, Nadège had to be retrievable. If the abstract did not present sufficient et al. assessed the effect of nine pairs of heel height (0 cm, details for any of the eligibility criteria, the reviewers would 2 cm, 3 cm, 4 cm, 5 cm, 6 cm, 7 cm, 8 cm, 9 cm) on kinematic Applied Bionics and Biomechanics 3 Results of database search: 906 records (276 PubMed, 243 Scopus, 187 Web of Science, 200 Embase) 544 records aer duplicates removed 362 records screened 276 records excluded 78 records excluded with 86 full-articles assessed for eligibility improper inclusion criteria 8 articles included Figure 1: Flowchart of the search strategy. Table 1: Basic information on selected articles. Number [ref.] Author/date Title Journal Concentration Wearing high-heeled shoes during gait: 1 [27] Nadège et al. 2015 kinematics impact and determination American Journal of Life Sciences Heel height of comfort height The changes of COP and foot pressure 2 [28] Ko and Lee 2013 after one-hour walking wearing high-heeled Journal of Physical Therapy Science Heel height and flat shoes Effects of heel base size, walking speed, and slope angle on center of pressure 3 [30] Luximon et al. 2015 Human Movement Science HBS trajectory and plantar pressure when wearing high-heeled shoes Effect on plantar pressure distribution with Journal of Mechanics in Medicine 4 [29] Guo et al. 2012 wearing different base size of high-heel NBS and Biology shoes during walking and slow running Effect of shoe heel height and total-contact 5 [31] Hong et al. 2013 insert on muscle loading and foot stability Foot and Ankle Society Insert insole while walking Biomechanical effects of foam inserts on Journal of Mechanics in Medicine 6 [7] Li et al. 2010 forefoot load during the high-heeled gait: Insert insole and Biology a pilot study Influence of heel height and shoe insert on comfort perception and biomechanical 7 [8] Hong et al. 2005 Foot and Ankle International Insert insole performance of young female adults during walking Effects of shoe inserts and heel height on 8 [22] Yung and Wei 2005 foot pressure, impact force, and perceived Applied Ergonomics Insert insole comfort during walking parameters, in which the stride length (SL), swing phase walking for 1 hour in 0.5 cm, 4 cm, and 9 cm shoes, respec- (DSwp), duration of the stance phase (DStp), swing phase tively [28]. Results presented that 4 cm heel height is the most (DSwP), and gait ratio were included, as well as heart rate suitable, since this height is accompanied with stable COP [27]. The results indicated that the most comfortable heel tendency and less plantar pressure than walking in 0.5 cm or 9 cm shoes. Details are presented in Table 3. height is 4:13 ± 0:34 cm, which is accompanied with less dis- ruptive locomotor pattern and optimal heart rate, compared to other heights. Differently, Ko and Lee determined the most 3.2.2. HBS. Two studies were associated with the effect of comfortable heel height for HH shoes by detecting the dis- HBS on distribution of plantar pressure patterns, COP trajec- placement of the COP and plantar pressure change after tory, and perceived comfort. A large HBS demonstrated Included Eligibility Screening Identification 4 Applied Bionics and Biomechanics Table 2: Methodological quality of included studies by using the McMaster critical appraisal form. Study design Level Items Score Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1 CCT III-2 √√ √√√ √ x √ n/a √√ √√ x √ 12/14 2 CCT III-2 √√ √√√ x √√ n/a √√ √√ x √ 12/14 3 CCT III-2 √√ √√√ x √√ n/a √√ √√√√ 13/14 4 CCT III-2 √√ √√√ x √√ n/a √√ √√ x √ 12/14 5 CCT III-2 √√ √√√ x √√ n/a √√ √√ x √ 12/14 6 CCT III-2 √√ √√ xx √√ n/a √√ √√√√ 12/14 7 CCT III-2 √√ √√√ x √√ n/a √√ √√ x √ 12/14 8 CCT III-2 √√ √√√ x √√ n/a √√ √√ x √ 12/14 Level of evidence (based on NHMRC hierarchy); CCT: control clinical trial; FU/RCT: follow-up study from randomized control trial. √: yes; x: no/not reported; n/a: not applicable. McMaster Items: (1) study purpose clearly stated; (2) background literature reviewed; (3) appropriate research design; (4) sample described in detail; (5) sample size justified; (6) outcome measure reliability reported; (7) outcome measure validity reported; (8) intervention described; (9) contamination avoided; (10) cointervention avoided; (11) results reported in terms of statistical significance; (12) appropriate analysis method; (13) clinical significance reported; (14) dropouts reported; (15) appropriate conclusion. smaller maximal peak pear pressure in the rearfoot, midfoot, tion [7, 22, 32, 33]. The effect of four different types of foam and forefoot compared to small HBS [29, 30]. It must be insoles (soft 5 mm, soft 10 mm, hard 5 mm, hard 100 mm) in noted that the scale of HBS affects the COP location in the the targeted MF region on plantar pressure was tested. There anterior-posterior direction at the end of the stance phase. was a great advantage in soft 5 mm to reduce peak pressure The COP deviations are increased with a small HBS when by 26%, impact force by 27% in MF region compared to the compared to a large HBS [30]. Only one study reported infor- noninsert condition [7]. All the above insole types are pre- mation about the stability as a function of HBS. It can be con- sented in Figure 2(a). More details on female insert insoles cluded that a large HBS can lead to a more stable gait during are presents in Table 5. walking with HH [30]. Details are presented in Table 4, and different sizes of HBS are shown in Figure 2(b). 4. Discussion 3.2.3. Insert Insole. Four included studies evaluated the effect To reach a full understanding of how the design factors of of insert insole on kinematic, kinetic, EMG, and comfort rat- high-heeled shoes affect locomotor pattern, disturbance of ing of the lower extremity, but different types of insole were plantar pressure, and perceived comfort is crucial. This used for each study. One study investigated how subject’s review identified 8 articles, which appraised either the effect rearfoot kinematic, muscle activity, and subjective comfort of heel height, HBS, or insert insole on lower limb kinematic, were affected by TCI which were designed from rearfoot to kinetic, or EMG during waking with HH, as well as perceived metatarsal head during walking with HH (Figure 2(b) [31]. comfort. When compared with a noninsert condition, results showed that the use of a TCI could reduce peak MG by 19.0% and 4.1. Heel Height Studies. There are only two studies that eval- peak ES by 21.5% in HH with 7.6 cm, and rearfoot inversion uated the comfort heel height of HH by using different angle was significantly decreased. But this study did not pres- methods, and a consensus has been formed that shows that ent kinetic variation of the foot. Another included article the appropriate heel height in high-heeled shoes is 4:13 ± used an insole from the rearfoot to metatarsal head (TCI II) 0:34 cm [27, 28]. In addition, this result is also consistent that was designed by the orthotist to fit each participants’ foot with Ko who reported that the preferable heel height was to determine the effect of shoe inserts on plantar pressure, between 3 cm and 5 cm, but this article as a conference paper GRF, and perceived comfort during walking in different heel failed to be selected in this review [34]. A growing number of height shoes (1.0 cm, 5.1 cm, 7.6 cm) (Figure 2(b)) [8]. researches indicate that musculoskeletal systems are directly Results showed that the peak pressure of the medial forefoot modified from wearing HH. On the other hand, the human reduced by using TCL compared with noninsert shoes, and it foot naturally presents a moderate imbalance in body weight was more effective to use TCI in the higher heels than lower (BW) distribution; i.e., 43% of BW is loaded to the foot and flat heels. Furthermore, Yung and Wei also found that a front, with the remaining 57% at the heel portion when TCI decreased heel pressure by 25%, medial forefoot pressure walking barefoot. For that reason, a slight heel height shoe by 24%, and impact force by 33% [22]. (2 cm) is recommended to be used by orthopedic specialists, While the heel cup pad could decrease the heel pressure since it can balance the distribution of plantar pressure to and impact force and the use of single arch support inserts relieve rearfoot load [21]. But these outcomes depend on can attenuate the medial forefoot pressure, no special short-term testing rather than for a long period. Therefore, changes to the metatarsal pad using measured parameters the results of a suitable heel height in included articles may were found [22]. The medial forefoot (MF) has been consid- not predict the impact of wearing high-heeled shoes in the ered the most sensitive area in response to heel height varia- long term. Applied Bionics and Biomechanics 5 Table 3: Summary of articles related to the effect of appropriate heel height among females. Participant characteristics Walking Shoe condition Number (mean ± standard deviation) speed Variables measured Purpose Main findings N Age (years) Height (m) Weight (kg) HBS (cm ) Height of heel (cm) (cm/s) (i) SL (ii) DStP 0% Ffcwh To determine the (i) The comfort heel height was 22:40 ± 2:56 1:63 ± 0:04 59:07 ± 5:15 115 5.3 0, 2, 3, 4, 5, 6, 7, 8, 9 +20% Ffcwh (iii) DSwP comfort heel height for 4:13 cm ± 0:34 -20% Ffcwh the shoe (iv) Gait ratio (v) Heart rate (i) The distribution of foot pressure and COP did not change (i) Foot pressure To determine the most significantly in 4 cm heel height 215 20:90 ± 1:30 1:60 ± 3:30 52:10 ± 5:0 — 0.5, 4, 9 1.17 appropriate height for after walking shoe heels (ii) 4 cm heel height was (ii) COP preferable for health and comfort Note: Ffcwh: step frequency freely chosen in shoes without heel; SL: stride length; DStP: duration of the stance phase; DSwP: swing phase; COP: central of pressure. 6 Applied Bionics and Biomechanics Table 4: Summary of articles related to the effect of HBS on female. Participant characteristics Shoe condition (mean ± standard deviation) Walking Number Variables measured Purpose Main findings Height of speed (cm/s) N Age (years) Height (m) Weight (kg) HBS (cm2) heel (cm) (i) Smaller COP deviations in (i) COP larger HBS (ii) The walking speed mainly (ii) Perceived affected stability the locations of the COP in the Evaluated the effects of the anteroposterior direction during gait 315 22:50 ± 4:70 1:61 ± 0:04 51:30 ± 4:90 -0.88, -8.92 3 112, 143 HBS of HH shoes (iii) A maximal peak pressure increased over the forefoot, midfoot, (iii) Plantar and rearfoot in larger HBS pressure (iv) The participants felt more stable in larger HBS (i) Smaller plantar pressure in medial, Be better to select one with 22:0±0:81:60 ± 3:30 52:10 ± 5:0 413 -1.44, -7.7 7.8 100, 115, 200 (i) Plantar pressure central, and lateral of forefoot and toe a wide-based heel regions in larger HBS Note: COP: central of pressure; HBS: heel base support; HH: high heels. Applied Bionics and Biomechanics 7 Medial forefoot pad Metatarsal pad Total contact insert Arch support pad Heel cup pad Total contact insert II (a) (b) Figure 2: (a) The different insert pads mentioned in included studies. (b) The total contact insert, total contact insert II (from rearfoot to metatarsal head), and small and large heel base size mentioned in included studies. Note: (a) and (b) do not represent the actual ones used in the included study. 4.2. HBS Studies. The scale of HBS is another important fac- [22]. An arch support insole decreased peak pressure by tor influencing locomotor pattern during gait with HH. The 15% in the medial forefoot region and raised the pressure by 125.6% in the midfoot region, since it was used to prevent narrow heels are the most commonly used design in HH which increase plantar pressure, especially in the heel region depression of the longitudinal arch during weight bearing, and lead to instability [22, 35, 36]. Luximon et al. noted that thereby alleviating the tension of the plantar aponeurosis the maximal peak pressure uniformly increased over the [22, 41, 42]. Weight bearing can be transferred from the fore- whole plantar in large HBS, whereas a narrowed HBS pre- foot to the longitudinal and metatarsal arches by the metatar- sented higher maximal peak pressure in the toe region [30]. sal pad; however, no changes in pressure and impact forces This result is partially similar to Guo et al. whose research were found in the medial forefoot region reported by Yung showed that the plantar pressure of hallux was significantly and Wei [22]. Furthermore, medial forefoot pads with differ- increased in small HBS compared to large HBS [29]. Except ent foam hardness and thickness were utilized; and the for the impact of heel height, the narrow HBS may be a direct results showed that the thick soft pad can effectively reduce reason contributing to hammer toe which is caused by exces- larger pressure and impact force caused by HH in the medial sive pressure on the metatarsal-phalangeal region during forefoot when compared to other types [7, 43]. walking with HH. Additionally, a smaller HBS presented a In terms of using TCI, three included studies indicated that TCI relieved pressure and impact force on multiple areas larger COP deviation which triggered gait instability, where the toes had to grip the sole of shoes to keep stable. This of the foot simultaneously and significantly improved per- scenario may be another reason that could lead to the devel- ceived comfort during walking with HH [8, 22, 31]. The opment of a hammer toe when wearing HH [30]. TCI provides a highly conforming fit between the foot and It must be noted that only one heel height was used to the contact surface of the insole, as well as spreading and redistributing pressure over the rearfoot, midfoot, and fore- measure the function of using different HBS in two selected studies. Although previous researchers suggested that a foot. Notably, the current research notes that the use of TCI decreased HBS rather than an increased heel height was the is the most effective way to attenuate pressure in comparison main element for reducing stability during walking with to other single pads during walking with HH. Further studies HH [37], the different sizes of HBS combined with diverse are needed to evaluate the effect of different thicknesses and material properties of TCI on load and pressure redistribu- heel height should be assessed in the future to further con- firm the effectiveness of HBS on gait stabilization. tion during walking with HH shoes. What is more, the effec- tiveness of insoles also needs to be estimated in the long term 4.3. Insert Insole Studies. Insert insole has been widely used in to determine whether this type of intervention should be footwear to improve perceived comfort, absorbing energy recommended for women with high heels-related foot problems. attenuating impact forces, redistribute the plantar pressure, and reduce the risk of movement-related injury [38–40]. The various insert designs presented different kinetic modifi- 4.4. Limitations and Future Direction. The most obvious lim- cations during walking with HH. For instance, Yung and Wei itation in this review is the small sample size. Only 8 studies indicated that a heel cup pad reduced pressure by 24.3% and met our inclusion criteria hence the reason why a meta- analysis was not conducted. In addition, the effects of impact force by 18.6% in the heel region when wearing HH 8 Applied Bionics and Biomechanics Table 5: Summary of articles related to the effect of insert insole on female. Participant characteristics Shoe condition Number (mean ± standard deviation) Type of insole Variables measured Purpose Main findings N Age (years) Height (m) Weight (kg) Height of heel (cm) To investigate how shoe heel (i) The use of TCI reduced the (i) TCI II (from (i) Kinematic height and use of TCI in rearfoot inversion angle and in 24:5±4:5 159:3± 6:549:6± 6:4 515 1.0, 5.1, 7.6 rearfoot to (ii) EMG high-heeled shoes affect the wearer’s both QUA and ES muscles activity metatarsal head) (iii) Comfort rating rearfoot complex, muscle loading, (ii) Comfort rating increased by and subjective comfort using TCI (i) Thicker soft foam sole significantly (i) MF foams insole To determine the effect of foam reduced peak pressure in MF than with soft (5 mm), inserts in targeted medial foot thinner hard foams 22:0±2:0 163:0± 3:051:0± 4:5 68 0, 4.5, 8.5 (ii) MF soft 10 mm (i) Plantar pressure region on the foot pressure (ii) The maximum force and peak (iii) MF hard 5 mm distribution during normal pressure reduced in the MF region (iv) MF soft 10 mm walking bu using foams than no insole in HH (i) The comfort ratings were significantly increased when wearing with TCI (i) Perceived (ii) Use of the TCI reduced the To evaluate the effect of TCI stability peak pressure in the medial forefoot 720 25:4±3:8 157:8± 5:050:5± 4:2 1.0, 5.1, 7.6 (i) TCI insole on comfort perception and (ii) Plantar pressure (iii) Mean GRF decreased to 39% BW plantar pressure (iii) GRF in the highest shoes with the TCI (iv) It was more effective to use TCL in higher heels than in the lower heels and in flat heels (i) Heel cup insert reduced the heel pressure and impact force (ii) Arch support insert reduced (i) Heel cup pad Whether use of shoe inserts the medial forefoot pressure and (ii) Arch support (i) Plantar pressure change foot pressure distribution, 23 ± 3:4 160 ± 3 50 ± 3 810 1.0, 5.1, 7.6 improved comfort (iii) Metatarsal pad (ii) Comfort rating impact force, and perceived (iii) TCI reduce heel pressure, (iv) TCI comfort during walking medial forefoot pressure, and impact force and provided a higher perceived comfort Note: TCI: total contact insert; MF: medial forefoot; GRF: grand reaction force; BW: body weight; QUA: quadriceps; ES: erector spinae; EMG: electromyography. 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Applied Bionics and BiomechanicsHindawi Publishing Corporation

Published: Mar 15, 2021

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