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

doi:10.21203/rs.3.rs-16287/v1

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Research article

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

https://doi.org/10.21203/rs.3.rs-16287/v1

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published 01 Jan, 2020

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Background Between 39% and 69% of women wear high-heeled shoes. Previous studies have shown that high heels can induce adverse biomechanical effects, but variables, such as walking speed, structure, style, and material of the shoes, have not been strictly controlled. The purpose of this study is to investigate the influences of high-heeled shoe parameters on gait cycle, center of pressure 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 high-heeled shoes were evaluated, which consisted of 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 one pair of flat shoes (with 0.6 cm heel height) as the control group, while they walked on the treadmill at the same speed. Results and their significance were evaluated using a Heel Height × Heel Type Two way repeated ANOVA Test. Results The main parameters measured were the gait cycle, center of pressure parameters, peak pressure (PP), maximum force, contact area (CA), and the force time integral (impulse). The comparison of these parameters, conducted when the volunteers wore thick heel and flat shoes at different walking conditions, indicated that thin heels caused significant increases in the preswing parameter, CA, and PP exerted on 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 in the case of the forefoot. Conclusions Data analyses showed significant differences in plantar pressure distribution associated with the heel height and heel type at increased pressure in the central forefoot region and decreased pressure in the midfoot and heel sections, which consisted of the increased anterior shift. The implication of this study is to provide scientific advice to women for their choices of high heel shoes.

Orthopedics

High-heeled shoe parameter

gait cycle

treadmill walking

plantar pressure

Throughout history, high-heeled shoes (HHS) have been extensively used to increase the height and improve the profile of the wearer. According to the American Podiatric Medical Association, 39–69% of women wear HHS, while 40% of these women wear them daily [1–3]. However, wearing HHS may induce side effects on bones and the musculoskeletal system, and cause lower back discomfort, forefoot pain, and hallux valgus [4–7].

Moreover, several studies showed that high heels cause alterations in balance and are responsible for changes in the center of pressure (COP) and plantar pressure (PP) [8–10]. Previous literature indicated that the trajectory of COP had always been used to assess walking stability. Multiple COP parameters, such as the medial–lateral positions, anterior–posterior positions, and the average distance of COP from the mean position, were sensitive to deviations during extra inversion or eversion [9].

Previous studies have shown that the heel rise can induce adverse biomechanical effects, which may lead to an uneven distribution of plantar pressure. In turn, this would reduce the stress on the hindfoot and increase the stress to the forefoot [11]. Furthermore, these reported changes in forefoot pressure have been associated with the impacts of HHS on foot deformities, including the development of metatarsalgia, callus formation, increased rates of ulceration under the metatarsal heads, and the subsequent risk of painful bony deformities [12, 13].

Research on heel height and heel type of high heels has been carried out worldwide based on gait patterns on the ground or in other forms [14, 15]. However, to the best of our knowledge, this is the first time a treadmill was used in a survey of HHS. Additionally, as this paradigm needed a smaller space and allowed the use of harness support systems, it could be compared with more standardized conditions (e.g., constant walking speed) [16, 17]. Accordingly, treadmill gait analysis was an attractive alternative.

Furthermore, most shoes used for research are non-customized, not only in terms of the structure and style of the test shoes, but also in terms of the material of the shoe. These factors result in non-negligible errors and affect the accuracy of the research conclusions.

The shoes used in this study were customized, which reduced the human error and improved the accuracy of the research. By studying the influences of the differences in heel structure on the gait cycle, COP, and PP at a fixed walking speed, this study attempted to provide scientific advice to women for their high heel choices.

The survey participants included 20 female adult volunteers (mean age ± standard deviation: 21.22 ± 4.04 years, height: 162.0 ± 0.5 cm, weight: 55.80 ± 5.05 kg, and body-mass index (BMI): 20.73 ± 2.05 kg/m²) with a foot size of 37 (European standard). Most of the participants wore HHS one to four times per week. All participants reported no foot-related disorders, skin lesions, or health-related problems. Signed written consent was obtained from all participants before the experiments. The study design was approved by the Ethics Committee of Huashan Hospital of Fudan University. The participants were examined while walking on treadmill at a fixed speed (1 m/s) at seven experimental conditions: (A1) thick HHS with 3 cm heels, (A2) thick HHS with 6 cm heels, (A3) thick HHS with 8.2 cm heels, (B1) thin HHS with 3 cm heels, (B2) thin HHS with 6 cm heels, (B3) thin HHS with 8.2 cm heels, and (C) flat shoes (Fig. 1a). All of the shoes were made at the Shanghai Second Leather Shoe Factory with the same type of material.

The EBRIS® gait analysis system and Noraxon myoPRESSURE™ module were operated with the treadmill system (Noraxon USA, Inc.) at a frequency of 100 Hz. The treadmill speed was set to 1 m/s. During the experiments, the participants were given several minutes to become accustomed to the HHS and were required to gradually walk along a track twice with each pair of shoes. Each session lasted approximately 10 s. MyoPRESSURE™ presented a comprehensive analysis of standard gait parameters and the COP. Associated average curves were generated. Plantar pressure measurements were recorded using the Tekscan® F-Scan® system (Tekscan Inc., South Boston, MA, USA) simultaneously. This system consisted of a wireless transmitter and two sensors. These sensors were approximately 0.15 mm thick and comprised 960 sensing elements, distributed in four sensors/area (cm²). A sampling rate of 500 Hz was utilized for all the trials. All data were collected and processed using the Tekscan® F-Scan® research software (version 7).

All analyses were performed for the right foot (dominant side) [18]. In order to analyze the influences of heel height and heel type on gait parameters, A two-way repeated ANOVA was performed to determine which variables were affected by heel type and which were affected by heel height or a combination of both. For each statistical test, the significance was set at 0.05. When the tests were significant, the least significant difference criterion was adopted for post hoc comparisons. Statistical analyses were performed with the built-in functions of SPSS 21 (IBM Corp., Armonk, NY, USA).

Normality information about this study we used the KS-test(Kolmogorov-Smirnov test)for the participants’ body weight and height, the P value are 0.761 and 0.522, both were in normal distribution.

Gait phase parameters

The results of all gait phase parameters, for two heel types (thin and thick) and three different conditions (low: 3 cm, medium: 6 cm, and high: 8.2 cm), with a pair of flat shoes as the control group, are listed in Table 1. The stance phase was separated into three subphases: loading response (LR), midstance (MS), and preswing (PS).

The Heel Height × Heel Type two-way repeated ANOVA showed that the interaction factor and main effect heel height were not statistically different for the selected conditions. Meanwhile, the heel type only showed significant differences in the PS parameter. The post-hoc results showed significant differences between the control group and thin-heeled group, and also between the thick-heeled group and thin-heeled group.

COP parameters

The results of COP parameters, including the gait line length, medial–lateral position, anterior–posterior position, and single support line for two heel types (thin and thick), and three different conditions (low: 3 cm, medium: 6 cm, and high: 8.2 cm), with a pair of flat shoes as the control group are reported in Table 1.

The Heel Height × Heel Type two-way repeated ANOVA showed that neither the interaction factor nor the heel height and heel type was statistically different for the medial–lateral position.

Conversely, the main effect heel height and the interaction factor showed significant differences for the following parameters: gait line length, single support line, and anterior–posterior position. Regarding COP parameters, the post-hoc analysis revealed significant differences in the gait line length and single support line. However, the results for the anterior–posterior position yielded statistically significant differences between the control and high-heeled groups, low-heeled and medium-heeled groups, low-heeled and high-heeled groups, and between the medium-heeled and high-heeled groups.

Table 1

Gait phase parameters and COP parameters (n = 20, P = 0.05)
	Thick heel group Mean (SD)			Thin heel group Mean (SD)			Flat shoe Mean (SD)	Main effect Heel type p-value	Main effect Heel height p-value	Mixed anova test (type*height) p-value
	3cm	6cm	8.2 cm	3cm	6cm	8.2 cm
Stance phase,%	67.01(1.40)	67.28(1.43)	67.04(1.45)	66.33(1.55)	66.82(1.40)	67.06(1.36)	66.44(1.49)	0.099	0.272	0.428
Load responce,%	16.91(1.24)	17.06(1.57)	16.95(1.45)	16.48(1.58)	16.70(1.53)	16.86(1.47)	16.37(1.52)	0.192	0.706	0.811
Mid stance,%	32.92(1.73)	32.96(1.69)	33.22(1.52)	33.58(1.44)	33.43(1.57)	33.28(1.56)	33.80(1.55)	0.098	0.971	0.586
Pre-swing,%	16.27(1.37)	16.69(1.36)	16.95(1.29)	16.88(1.50)	17.18(1.64)	17.28(1.47)	16.28(1.44)	0.031 b c	0.128	0.868
Swing phase,%	32.98(1.40)	32.72(1.43)	32.96(1.45)	33.67(1.55)	33.18(1.40)	32.94(1.36)	33.56(1.73)	0.096	0.282	0.418
Double phase,%	34.08(2.59)	34.35(2.87)	33.83(2.64)	32.74(2.62)	33.40(2.65)	33.79(2.57)	32.64(2.75)	0.058	0.605	0.405
Length of gait line,mm	224.00(6.51)	211.31(8.62)	194.88(9.47)	215.67(5.570	214.65(7.23)	203.72(6.56)	239.44(7.09)	0.254	0.000 &*#%§¥	0.000
Single support line,mm	83.98(20.99)	67.22(16.71)	45.18(12.54)	83.38(17.29)	62.50(14.54)	41.16(11.52)	102.71(15.86)	0.198	0.000 &*#%§¥	0.000
Medial-lateral position,mm	−1.21(6.71)	0.05(5.97)	−2.27(8.12)	−1.75(4.48)	−1.72(3.25)	−1.78(5.92)	−1.37(3.70)	0.486	0.531	0.565
Anterior-posterior position,mm	143.24( 14.40)	145.07(15.10)	145.66(13.13)	131.84(8.54)	144.74(11.25)	153.22(10.58)	141.10(10.03)	0.489	0.000*#&%	0.000

§Statistically significant difference between control group and low heeled group.

¥ Statistically significant difference between control group and medium heeled group.

& Statistically significant difference between control group and high heeled group.

* Statistically significant difference between low heeled group and medium heeled group.

# Statistically significant difference between low heeled group and high heeled group.

% Statistically significant difference between medium heeled group and high heeled group.

b Statistically significant difference between control group and thin heeled group.

c Statistically significant difference between thick heeled group and thin heeled group.

Plantar pressure parameters

The plantar surface was divided into eight anatomical regions, including great toe (T1), lesser toes (T2–5), first metatarsal (M1), central forefoot (M23), lateral forefoot (M45), midfoot (MF), medial heel (MH), and lateral heel (LH) (Fig. 1b).

The heel height changed the maximum force over the entire foot region (Table 2). The heel height increased the maximum force over the T1, T2–5, M1, and M23, whereas a smaller force acted on the MF and MH regions. As shown in Table 3, the force–time integral exhibited patterns similar to those of the maximum force, i.e., lower force–time integral values in MH regions and higher in T1, T2–5, M1, and M23 regions.

As shown in Table 4, the contact area (CA) was larger in T1 and T2–5 with increased heel height. Moreover, the main effect of the heel type yielded significant differences in the T1 and M1 regions, while the post-hoc analysis results showed significant differences between the control and thin-heeled groups, the thick-heeled and thin-heeled groups, and between the thick heeled and thin heeled groups. Furthermore, the CA for the T1 was larger in the thick-heel group, while less CA was observed for M1 in the thin-heel group.

Table 5 shows the peak pressure (PP) results for eight anatomical regions. The PPs were larger in the T1, T2–5, M1, and M23 regions, and smaller in the MF, MH, and LH regions in high-heeled walking compared with the lower-heel height walking cases. The main effect of heel type yielded significant differences in the T1 and T2–5 regions, the post–hoc analysis results showed significant differences between the control and thin-heeled groups, the thick-heeled and thin-heeled groups, and also between the thick-heeled and thin-heeled groups. Additionally, both the PP for the T1 and T2–5 area were bigger in the thin-heel group than in the thick-heel group.

Maximum force(N)	Thick heel group Mean (SD)			Thin heel group Mean (SD)			Flat shoe Mean (SD)	Main effect Heel type p-value	Main effect Heel height p-value	Mixed anova test (type*height) p-value
Maximum force(N)	3cm	6cm	8.2 cm	3cm	6cm	8.2 cm
T1	44.96(21.80)	66.23(27.57)	65.95(19.37)	39.45(23.77)	50.11(19.29)	66.43(25.01)	17.42(14.51)	0.145	0.000 §¥ &*#	0.363
T2−5	43.14(31.01)	75.56(37.32)	88.21(34.64)	34.86(24.01)	61.88(20.35)	81.31(29.38)	17.09(11.66)	0.121	0.000 §¥ &*#	0.893
M1	61.63(33.73)	80.56(34.33)	102.63(46.56)	64.77(29.72)	92.31(34.87)	116.39(36.37)	52.85(33.30)	0.226	0.000 ¥ &*#%	0.842
M23	80.95(45.03)	102.40(37.57)	105.33(52.22)	72.70(36.52)	105.71(36.73)	120.61(52.96)	59.92(41.06)	0.718	0.007 ¥ &*#	0.603
M45	45.37(31.61)	47.85(32.35)	44.13(18.97)	44.53(20.89)	55.74(27.29)	52.60(28.27)	35.32(22.55)	0.372	0.627	0.762
MF	82.77(47.12)	53.35(36.67)	42.53(26.69)	101.60(59.47)	62.23(45.41)	38.85(23.01)	126.62(79.54)	0.455	0.001 §¥ &*#	0.690
MH	247.74(96.64)	181.15(62.47)	139.87(36.33)	254.03(85.23)	168.88(48.32)	125.60(53.29)	247.26(91.18)	0.664	0.000 ¥ &*#%	0.837
LH	108.33(35.68)	86.10(34.60)	86.58(21.18)	106.32(33.46)	92.28(17.51)	82.81(26.10)	150.25(99.22)	0.989	0.157	0.911
§Statistically significant difference between control group and low heeled group.

Table 2 Maximum force (n = 20, P = 0.05)

¥ Statistically significant difference between control group and medium heeled group.

& Statistically significant difference between control group and high heeled group.

* Statistically significant difference between low heeled group and medium heeled group.

# Statistically significant difference between low heeled group and high heeled group.

% Statistically significant difference between medium heeled group and high heeled group.

Table 3

Force time integral (n = 20, P = 0.05)
Force time integral (N.S)	Thick heel group Mean (SD)			Thin heel group Mean (SD)			Flat shoe Mean (SD)	Main effect Heel type p-value	Main effect Heel height p-value	Mixed anova test (type*height) p-value
Force time integral (N.S)	3cm	6cm	8.2 cm	3cm	6cm	8.2 cm
T1	0.90(0.25)	1.23(0.44)	1.32(0.39)	0.79(0.26)	1.00(0.39)	1.33(0.30)	0.35(0.11)	0.158	0.000 §* #%	0.457
T2−5	0.86(0.62)	1.51(0.75)	1.76(0.69)	0.70(0.48)	1.24(0.41)	1.63(0.59)	0.34(0.23)	0.121	0.000 §¥ &*#%	0.893
M1	1.23(0.67)	1.61(0.69)	2.05(0.93)	1.30(0.59)	1.85(0.70)	2.33(0.73)	1.06(0.67)	0.226	0.000 ¥ &*#%	0.842
M23	1.34(0.62)	2.05(0.75)	2.11(1.04)	1.45(0.73)	2.11(0.73)	2.41(1.06)	1.20(0.82)	0.718	0.007 ¥ &*#	0.603
M45	1.34(0.62)	2.05(0.75)	2.11(1.04)	1.45(0.73)	2.11(0.73)	2.41(1.06)	1.20(0.82)	0.372	0.627	0.762
MF	1.66(0.94)	1.07(0.73)	0.85(0.53)	2.03(1.19)	1.24(0.91)	0.68(0.30)	2.53(1.59)	0.310	0.546	0.704
MH	4.95(1.93)	3.62(1.25)	2.80(0.73)	5.08(1.70)	3.38(0.97)	2.73(0.80)	4.95(1.82)	0.842	0.000 §¥ *#	0.884
LH	2.17(0.71)	1.72(0.69)	1.73(0.42)	2.13(0.67)	1.85(0.35)	1.66(0.52)	3.00(1.98)	0.989	0.157	0.911

§Statistically significant difference between control group and low heeled group.

¥ Statistically significant difference between control group and medium heeled group.

& Statistically significant difference between control group and high heeled group.

* Statistically significant difference between low heeled group and medium heeled group.

# Statistically significant difference between low heeled group and high heeled group.

% Statistically significant difference between medium heeled group and high heeled group.

Table 4

Force time integral (n = 20, P = 0.05)
Contact area (cm2)	Thick heel group Mean (SD)			Thin heel group Mean (SD)			Flat shoe Mean (SD)	Main effect Heel type p-value	Main effect Heel height p-value	Mixed anova test (type*height) p-value
Contact area (cm2)	3cm	6cm	8.2 cm	3cm	6cm	8.2 cm
T1	3.88(1.34)	5.08(1.07)	5.78(0.98)	3.21(1.40)	4.62(0.91)	5.37(1.02)	1.90(1.36)	0.040 abc	0.000 §¥ &*#%	0.937
T2−5	5.46(3.05)	8.01(3.18)	8.82(2.59)	4.80(2.80)	7.17(1.62)	7.96(2.18)	2.25(1.72)	0.157	0.000 §¥ &*#	0.987
M1	5.37(1.97)	5.78(1.76)	6.60(1.58)	6.27(2.05)	6.97(1.77)	7.21(1.10)	4.28(2.14)	0.029 abc	0.104	0.844
M23	6.40(2.08)	6.54(1.77)	6.71(1.70)	6.27(2.80)	7.31(1.36)	6.62(1.25)	6.77(3.90)	0.722	0.629	0.712
M45	5.31(2.85)	5.33(3.20)	5.42(2.27)	5.42(2.75)	6.15(2.62)	6.39(2.28)	4.76(3.09)	0.301	0.759	0.830
MF	9.84(4.20)	8.12(5.06)	7.20(3.79)	12.15(5.11)	9.30(4.74)	6.26(2.91)	13.47(6.67)	0.416	0.005 ¥&#	0.438
MH	13.94(2.06)	13.62(2.64)	13.32(1.75)	13.71(1.59)	13.57(0.80)	12.85(2.34)	13.83(2.25)	0.579	0.376	0.929
LH	9.16(1.51)	9.16(2.06)	9.92(1.73)	9.14(1.69)	9.79(1.51)	9.43(2.08)	10.33(4.06)	0.940	0.685	0.648

§Statistically significant difference between control group and low heeled group.

¥ Statistically significant difference between control group and medium heeled group.

& Statistically significant difference between control group and high heeled group.

* Statistically significant difference between low heeled group and medium heeled group.

# Statistically significant difference between low heeled group and high heeled group.

% Statistically significant difference between medium heeled group and high heeled group.

a Statistically significant difference between control group and thick heeled group.

b Statistically significant difference between control group and thin heeled group.

c Statistically significant difference between thick heeled group and thin heeled group.

Table 5

Peak pressure (n = 20, P = 0.05)
Peak pressure(KPa)	Thick heel group Mean (SD)			Thin heel group Mean (SD)			Flat shoe Mean (SD)	Main effect Heel type p-value	Main effect Heel height p-value	Mixed anova test (type*height) p-value
Peak pressure(KPa)	3cm	6cm	8.2 cm	3cm	6cm	8.2 cm
T1	10.12(2.63)	11.02(1.82)	12.32(1.66)	11.69(2.43)	12.49(2.92)	13.79(3.21)	7.80(2.41)	0.010 abc	0.011 §¥& #	0.996
T2−5	7.24(1.17)	8.81(1.49)	9.64(1.44)	8.02(1.75)	9.27(1.58)	10.60(2.05)	5.61(1.43)	0.034 abc	0.000 §¥&* #%	0.737
M1	10.45(3.37)	13.14(2.42)	14.16(2.98)	10.13(2.62)	13.12(3.22)	17.27(2.77)	9.40(2.43)	0.141	0.000 ¥&*#%	0.050
M23	12.34(5.02)	15.56(4.32)	15.46(5.44)	11.50(3.58)	14.38(3.99)	18.09(6.24)	9.13(2.80)	0.837	0.001 ¥&*#	0.238
M45	8.32(2.45)	9.08(2.04)	8.20(1.58)	8.89(2.63)	8.75(1.96)	9.59(2.56)	7.8(2.4)	0.274	0.851	0.364
MF	8.02(1.24)	6.64(1.58)	5.68(0.99)	8.35(2.13)	6.19(1.19)	6.09(0.86)	9.16(1.68)	0.790	0.000 ¥ &* #	0.538
MH	17.27(4.3)	13.39(2.85)	10.43(1.72)	18.59(4.4)	12.27(2.6)	10.42(2.3)	18.48(3.84)	0.820	0.000 ¥&*#	0.603
LH	11.69(2.98)	9.47(3.05)	8.76(1.68)	11.78(3.49)	9.58(1.94)	8.79(1.97)	13.6(4.46)	0.820	0.000 ¥&*#%	0.603