Journal of Electromyography and Kinesiology 24 (2014) 258–263

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Journal of Electromyography and Kinesiology

journal homepage: www.elsevier.com/locate/jelekin

Review

The effects of high heeled shoes on female gait: A review

Neil J. Cronin ⇑
Neuromuscular Research Centre, Department of Biology of Physical Activity, University of Jyväskylä, Finland

a r t i c l e i n f o a b s t r a c t

Article history: Walking is the most common form of human locomotion. From a motor control perspective, human
Received 19 September 2013 bipedalism makes the task of walking extremely complex. For parts of the step cycle, there is only one
Received in revised form 9 January 2014 foot on the ground, so both balance and propulsion are required in order for the movement to proceed
Accepted 14 January 2014
smoothly. One condition known to compound the difficulty of walking is the use of high heeled shoes,
which alter the natural position of the foot–ankle complex, and thereby produce a chain reaction of
(mostly negative) effects that travels up the lower limb at least as far as the spine. This review summa-
Keywords:
Gait
rises recent studies that have examined acute and chronic effects of high heels on balance and locomotion
Kinematics in young, otherwise healthy women. Controversial issues, common study limitations and directions for
Kinetics future research are also addressed in detail.
Muscle mechanics Ó 2014 Elsevier Ltd. All rights reserved.
Electromyography

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
1.1. General biomechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
1.2. Ground Reaction Forces (GRFs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
1.3. Back/spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
1.4. Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
1.5. Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
1.6. Foot and ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
2. Effects of experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
3. Methodological considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
4. Future directions and conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262

1. Introduction
Human bipedalism poses several difficulties for motor control.
Two thirds of the human body mass is located two thirds of body
height above the ground, so the body is an inherently unstable sys-
tem that requires a controller (Winter, 1995). Motor control is par-
ticularly complicated during common tasks like walking, where
there is only one foot on the ground for parts of the step cycle,
and both balance and propulsion are required. Shoe choice is
important in this regard, and can potentially alter both force pro-
files and motor control.
⇑ Address: Viveca 234, P.O. Box 35, Jyväskylä 40014, Finland. Tel.: +358 40 805
3735; fax: +358 14 260 2071.
E-mail address: neil.j.cronin@jyu.fi
While typical shoes have a heel elevation of less than 2 cm, high
heeled shoes (HH), defined as a shoe where the heel is higher than
the fore-part, may feature heel elevation in excess of 10 cm. HH of-
ten also include a narrow toe box, a rigid heel cap, and a curved
plantar region, all of which interfere with natural foot motion.
HH have been worn for several centuries (Stewart, 1972), and de-
spite numerous cautions against their use, they remain extremely
popular. Surveys suggest that between 37% and 69% of women
wear them on a daily basis, representing a huge proportion of
the female population (American Podiatric Medical Association,
2003; Frey et al., 1993; The Gallup Organization Inc., 1986).
HH disturb the natural function and position of the ankle joint
by forcing the foot into plantar flexion. Recently, many scientific
studies have examined the consequences of this positional change

1050-6411/$ - see front matter Ó 2014 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jelekin.2014.01.004
 N.J. Cronin / Journal of Electromyography and Kinesiology 24 (2014) 258–263
in terms of balance, gait and general wellbeing. The resulting data
show that the effects of HH are not localised to the foot, but instead
there is a chain reaction of effects that travels up the lower limb at
least as far as the spine. This review summarises studies that have
examined the effects of HH on parameters relevant to balance and
locomotion, primarily in young, healthy women, on whom the
majority of studies have focused.
1.1. General biomechanics
Higher heel heights contribute to slower self-selected walking
speeds and shorter strides, whereas cadence is generally un-
changed (Adrian and Karpovich, 1966; Barkema et al., 2012; Cronin
et al., 2012; Esenyel et al., 2003; Lee et al., 2001; Opila-Correia,
1990a). Energy cost is increased in HH when walking on a tread-
mill (Mathews and Wooten, 1963) or overground, and increases
systematically with heel height (Ebbeling et al., 1994). The freely
chosen walking speed in flat shoes is generally close to the most
energetically efficient, and walking faster or slower than this speed
increases energy cost, so the decrease in walking speed in HH likely
contributes to the higher energy cost of walking. As increases in
heel height further displace the centre of mass forwards and up-
wards, the resulting compensatory changes such as increased knee
flexion and increased lower limb muscle activity likely also con-
tribute to the higher energy cost when walking in HH (see below).
Blanchette et al. (2011) found an increase in friction demand with
increasing heel height. This suggests that the likelihood of slipping
increases when walking in HH on floor surfaces with lower friction,
which although intuitive, has yet to be verified experimentally.
1.2. Ground Reaction Forces (GRFs)
Consistent increases in vertical, anteroposterior, and/or medio-
lateral GRFs have been reported with higher heel heights in walk-
ing and standing, as have increases in loading rate (Cronin et al.,
2012; Ebbeling et al., 1994; Hong et al., 2005; Snow and Williams,
1994; Stefanyshyn et al., 2000; Yung-Hui and Wei-Hsien, 2005).
The larger braking forces in HH cause a greater deceleration of
the centre of mass, which has to be counteracted by an increase
in the peak propulsive force to accelerate the centre of mass again
at push-off (Stefanyshyn et al., 2000). Thus, as heel height in-
creases, gait patterns become less fluent, characterised by larger
accelerations and decelerations.
The ‘‘shock wave’’ consequent to higher forces at ground con-
tact may be transmitted up to the spine causing soft tissue damage,
ultimately contributing to leg and back pain and degenerative joint
disorders (Kerrigan et al., 1998; Voloshin and Wosk, 1982;
Voloshin and Loy, 1994). However, Loy and Voloshin (1987)
reported that when heel height increased from 7.6 cm to 8.5 cm,
both impact force and loading rate decreased, which may be an
injury prevention strategy employed at very high heel heights.
An interesting development in recent years is the use of insoles
to modify the forces in high heeled gait. Yung-hui and Wei-Hsien
(2005) found that a total contact insole combined with a
heel-cup and an arch-support mechanism attenuated the impact
force in HH by 33.2%. However, this study involved a single mea-
surement session, so the long-term effectiveness of these insoles
remains to be tested.
1.3. Back/spine
In the context of HH research, their effects on lumbar lordosis are
perhaps the most debated (discussed in (Russell, 2010; Russell et al.,
2012)). Most studies of the relationship between HH and lumbar
lordosis have found either a decrease (Bendix et al., 1984; Franklin
et al., 1995; Lee et al., 2001; Opila et al., 1988) or no significant
259
change in lordosis (Opila-Correia, 1990a; Snow and Williams,
1994) with increasing heel heights. Opila-Correia (1990b) found a
trend toward increased lordosis in HH, but only three of seven wo-
men showed this response. Lee et al. (2001) also reported increased
lordosis in five women aged between 20 and 30 when changing
from standing to walking (although their method has been criti-
cised; (Russell, 2010)). In a study of 13–20 year old girls, de Oliveira
Pezzan et al. (2011) reported that lordosis decreased in inexperi-
enced users of HH but increased in experienced users.
Numerous issues may contribute to these discrepancies. Indi-
vidual differences in adaptations to HH seem plausible, and may
be masked by only presenting group averages (see also (Barton
et al., 2009; Russell, 2010; Russell et al., 2012)). Methodological
issues such as the use of wooden boards as a substitute for HH
(Bendix et al., 1984; Franklin et al., 1995), different methods of
assessing lumbar curvature, different shoe wearing habits of the
subjects, accuracy of kinematic marker placement, small partici-
pant numbers, and/or variations in abdominal muscle activity
may also be contributing factors. Moreover, many studies were
only conducted in standing, making the issue of lumbar mechanics
during walking difficult to summarise. Clearly, a consensus on the
most appropriate method(s) of assessing lumbar curvature is
needed before firm conclusions can be reached. If HH do decrease
lordosis, additional compressive forces may occur in the lumbar
spine. Conversely, if long-term HH use leads to increased lordosis,
there may be accompanying changes in muscle–tendon properties,
as well as potential increases in fatigue and pain.
The vast majority of studies in this area have reported increased
muscle activity in the lower back when wearing HH, and this trend
increases with heel height (Barton et al., 2009; Lee et al., 2001;
Mika et al., 2011, 2012a). Conversely, Joseph (1968) found no
change in erector spinae activity in women walking in low-ele-
vated heels (suggesting that heel height may be responsible for
the lack of increase), and Bendix et al. (1984) found no change in
back or abdominal muscle activity with changes in heel height.
However, it should be noted that in the latter study, subjects stood
on wooden boards instead of wearing HH, and this condition is un-
likely to accurately represent the loading environment experienced
in HH. In terms of timing, elevated heel height leads to earlier on-
set of erector spinae activity (Barton et al., 2009; Bird et al., 2003).
Coupled with an increase in lumbar–abdominal co-activation, this
may contribute to balance maintenance by counteracting the ante-
rior lumbar displacement caused by increased heel height (Barton
et al., 2009; Lee et al., 2001).
In addition to increasing the energy requirements of the mus-
cles, sustained, large amplitude activation of lumbar muscles
may increase spinal compression, ultimately contributing to mus-
cle fatigue and low back pain (Bendix et al., 1984; Lee et al., 2001;
Mika et al., 2011). In fact, lumbar muscle contraction at intensities
as low as 2% of maximal strength can reduce tissue oxygenation,
and prolonged isometric contraction at this intensity has been
linked to lumbar repetitive strain injury (McGill et al., 2000). Thus,
even low levels of lumbar muscle activity maintained over long,
uninterrupted periods may result in negative tissue adaptations.
1.4. Hip
During the stance phase of walking, HH varying between 1 and
8 cm have generally been reported to have no effect on hip flexion
compared to flat shoes (Ebbeling et al., 1994; Opila-Correia, 1990a;
Snow and Williams, 1994). However, Kerrigan et al. (1998) re-
ported greater peak hip flexion and a brief rise in the hip-flexor
moment in early stance in HH. Esenyel et al. (2003) also observed
increased hip flexion in the stance-swing transition. In the swing
phase, hip flexion is slightly decreased in HH compared to flat
shoes or barefoot (Opila-Correia, 1990a). In the frontal plane,
260 N.J. Cronin / Journal of Electromyography and Kinesiology 24 (2014) 258–263
modestly higher peak hip abduction moments have been observed
with HH (Barkema et al., 2012; Esenyel et al., 2003), whereas
Kerrigan et al. (1998) found no differences. It seems that if biome-
chanical differences are present between HH and flat shoes at the
hip, they are generally small, especially compared to the changes
seen at the knee and ankle.
1.5. Knee
In general, the knee has been shown to be more flexed when the
foot contacts the ground in HH, as well as during the rest of
the stance phase (Kerrigan et al., 1998; Mika et al., 2012b;
Opila-Correia, 1990a), and the amount of knee flexion appears to
increase with increasing heel height (Blanchette et al., 2011;
Ebbeling et al., 1994). Accordingly, both the amplitude and
duration of knee extensor moments have been found to increase
(Cronin et al., 2012; Ebbeling et al., 1994; Ho et al., 2012; Simonsen
et al., 2012).
However, some studies have found no increase in peak knee
extensor moment during walking (Kerrigan et al., 2005; Snow
and Williams, 1994), which may be due to differences in walking
speeds and shoe heights. Walking speed influences joint moments
in the sagittal plane but not in the frontal plane (Kirtley et al.,
1985), and not all studies matched the walking speed between
barefoot and HH conditions, the latter generally involving slower
speeds. Shoe height also varied between approximately 3 and
10 cm in the different studies, and low heel heights likely evoke
smaller disturbances of joint mechanics. It may thus be the case
that at a given speed and with heel heights above a certain thresh-
old, walking in HH does increase the peak knee extensor moment
measurably. Other reported effects of HH at the knee include a lar-
ger range of motion during the stance phase (Ebbeling et al., 1994;
Simonsen et al., 2012) and decreased flexion during the swing
phase (Opila-Correia, 1990a; Snow and Williams, 1994).
The commonly reported increase in knee flexion during stance
occurs concurrently with increased quadriceps muscle electromy-
ography (EMG; (Mika et al., 2012b; Simonsen et al., 2012; Stefany-
shyn et al., 2000)). This may allow better attenuation of impact
forces and partly compensate for the loss of ankle dorsiflexion in
HH. However, the above changes also prolong patella tendon strain
and patellofemoral joint pressure, thereby increasing tibio-femoral
compressive forces, and possibly contributing to knee pain and
degenerative joint changes (Edwards et al., 2008; Reilly and Mar-
tens, 1972). In support of this hypothesis, Ho et al. (2012) reported
an 89.5% increase in peak patellofemoral joint stress in HH (9.53
versus 1.27 cm). A one mega pascal (MPa) reduction in patellofe-
moral joint stress has been suggested to decrease patellofemoral
pain by 56% (Powers et al., 2004). One MPa is equivalent to the dif-
ference observed by Ho et al. (2012) between the high and medium
shoe (6.35 cm) conditions. Thus, as well as decreasing patellofe-
moral joint stress, lower heel heights should decrease patellofe-
moral pain.
During walking, the weight of the body is medial to the knee,
which imposes a varus knee moment- a compressive force on the
medial aspect and a stretching force on the lateral aspect of the
knee. Walking in HH shifts the body weight further medially rela-
tive to the foot, increasing the varus moment (Barkema et al., 2012;
Esenyel et al., 2003; Kerrigan et al., 1998; Simonsen et al., 2012).
This is evident with heel heights as low as 3.8 cm (Kerrigan et al.,
2005), and a direct relationship between peak knee varus moment
and heel height has been demonstrated up to 9 cm at fixed and
self-selected speeds (Barkema et al., 2012). Moreover, Kerrigan
et al. (2001) found similar increases in varus moments between
wide and narrow based heels of the same height, confirming that
heel height is the parameter of importance, rather than other shoe
design parameters.
Increased varus moments may cause a compensatory increase
in lateral muscle forces around the knee, further increasing tibio-
femoral compressive forces with HH. Moreover, the increased
varus moment in HH may have long-term functional relevance.
For example, results from animal experiments have shown that
increasing varus moment at the knee leads to degenerative
changes in the medial compartment (Ogata et al., 1977). Osteoar-
thritic changes in human knees are also more common in the med-
ial compared to the lateral side, and osteoarthritis is twice as
common in women as in men, usually occurring bilaterally (Katz
et al., 1996). Accordingly, Kerrigan et al. (1998) suggested that
wearing HH contributes to osteoarthritis at the knee. Although log-
ically this hypothesis may seem appealing, it is important to stress
that no causal relationship has been established between HH-in-
duced varus moments and osteoarthritis risk. In order to do so,
the same individuals would need to be assessed repeatedly over
many years, and detailed information about shoe wearing habits
would need to be collected.
1.6. Foot and ankle
In HH there is an anterior, medial shift of forces within the foot;
forefoot forces increase, and the force concentration, shear stress
and loading rate at the first metatarsal head dramatically increase
whilst those over the fifth metatarsal head decrease (Cong et al.,
2011; Hong et al., 2005; Mandato and Nester, 1999; Nyska et al.,
1996; Snow et al., 1992; Yung-Hui and Wei-Hsien, 2005). This
change in force distribution (as well as the often tight fitting toe
box of HH) has been linked to forefoot deformities such as hallux
valgus (Cong et al., 2011; Frey et al., 1993; Mandato and Nester,
1999; Nyska et al., 1996; Snow et al., 1992; Yu et al., 2008), and
a correlation between heel height and hallux valgus prevalence
has been inferred (Menz and Morris, 2005). Other foot conditions
linked with HH include corns and calluses, metatarsalgia, Achilles
tendon tightness, plantar fasciitis and Haglund’s deformity, a pro-
trusion on the back of the calcaneus due to increased calcaneal
pressure (Ebbeling et al., 1994). At present, the precise conditions
leading to any of the above-mentioned foot deformities are un-
known. Different foot problems occur over different time courses,
but may also be affected differently by certain shoe characteristics,
such as heel height, toe box width and shoe sole material. Well-
controlled follow-up studies are needed to address these issues.
As well as foot deformity, habitual HH use has been linked with
foot pain, due partly to a reduced foot length and increased arch
height in HH (Gefen et al., 2002; Ricci and Karpovich, 1964). In a
sample of 356 women, Frey et al. (1993) reported that the majority
wore shoes that were too small for their feet and experienced foot
pain. A survey by the American Podiatric Medical Association also
found that 42% of women wore HH in spite of pain for aesthetic
reasons. Pain was commonly reported in the toes, ball of the foot,
heel and arch (American Podiatric Medical Association, 2003).
Moreover, HH are associated with sprained ankles, probably due
to decreased lateral ankle stability (Ebbeling et al., 1994; Nieto
and Nahigian, 1975). Recently, total contact insoles have been
shown to distribute forces more evenly within the foot in HH,
whilst also improving perceived comfort during walking (Hong
et al., 2005; Yung-Hui and Wei-Hsien, 2005). These results high-
light the potential of insoles to counteract some of the negative ef-
fects of HH on the foot. However, as stated above, the long-term
effectiveness of insoles needs to be assessed in order to determine
whether this type of intervention should be recommended for wo-
men with HH-related foot problems.
The increase in plantar flexion caused by HH leads to smaller
peak plantar flexor moments (and ankle range of motion) during
walking (Cronin et al., 2012; Esenyel et al., 2003; Kerrigan et al.,
1998, 2001; Simonsen et al., 2012). Simonsen et al. (2012)
 N.J. Cronin / Journal of Electromyography and Kinesiology 24 (2014) 258–263
suggested that this can be explained by the shorter triceps surae
fascicle lengths and smaller Achilles tendon moment arm, com-
bined with a GRF vector that passes closer to the ankle joint centre,
decreasing the moment requirement. However, it has been specu-
lated that Achilles tendon force actually increases due to increased
calf muscle activity in HH (Cronin et al., 2012; Simonsen et al.,
2012; Stefanyshyn et al., 2000). In any case, it may be that the
smaller sagittal plane plantar flexor moment observed when walk-
ing in HH is somewhat compensated by increases in both the
amplitude and duration of the knee extensor moment (see above).
Smaller plantar flexor moments may also imply a greater reliance
on proximal leg muscles such as the quadriceps to achieve leg pro-
pulsion when walking in HH.
In the frontal plane, the ankle inversion moment evident in
barefoot/low heel conditions switches to a progressively larger
eversion moment as heel height increases (Barkema et al., 2012;
Kerrigan et al., 1998). This is at least partly due to a lateral shift
of the ankle joint centre, which contributes to an inversion-biased
ankle orientation that must be counterbalanced by an eversion
moment. These changes in ankle kinetics may contribute to higher
medial compressive loading at the knee. In addition, sub-talar joint
pronation and internal tibial rotation are limited during heel strike
due to the more plantar flexed/supinated foot posture, and these
limitations may decrease the shock-absorbing capacity of the foot
during the early contact phase of gait (Opila-Correia, 1990a; Snow
and Williams, 1994).
HH are associated with increased muscle activity of the soleus,
tibialis anterior, medial gastrocnemius and peroneus longus
muscles, indicating increased coactivation around the ankle joint
(Cronin et al., 2012; Joseph, 1968; Opila-Correia, 1990a,b;
Simonsen et al., 2012; Stefanyshyn et al., 2000). Prolonged gastroc-
nemius activation has also been reported in HH (Cronin et al.,
2012), which is independent of age (Mika et al., 2012b). Increased
activation of the muscles around the ankle joint would increase
joint stiffness, and presumably somewhat compensates for the de-
creased stability caused by HH (Ebbeling et al., 1994; Joseph,
1968). However, as already stated, increased and prolonged muscle
activity contributes to the increased energetic cost of transport
when walking in HH (Ebbeling et al., 1994; Mathews and Wooten,
1963), and could also increase the likelihood of fatigue, particularly
when standing or walking in HH for prolonged periods.
Csapo et al. (2010) reported that long-term use of HH leads to
a shortening of the gastrocnemius muscle fascicles and an in-
crease in Achilles tendon size and stiffness, contributing to a
reduction in ankle range of motion. Achilles tendon hypertrophy
in habitual HH wearers may be an adaptation to the larger triceps
surae muscle forces when walking in HH (Csapo et al., 2010).
During standing, Csapo et al. (2010) and Cronin et al. (2012) both
found shorter muscle fascicles in habitual HH wearers than con-
trols, indicating chronic adaptations in muscle–tendon architec-
ture related to HH use. During walking, Cronin et al. (2012)
found that gastrocnemius muscle fascicle strains of habitual HH
wearers were 3 times higher and 6 times faster than when
walking barefoot, despite the smaller range of ankle rotation in
HH. This is consistent with the notion of increased Achilles ten-
don stiffness after long-term HH use (Csapo et al., 2010), although
increased knee flexion in HH may also affect the fascicle behav-
iour of the biarticular gastrocnemius muscle, since it crosses the
knee joint. In addition to contributing to gait inefficiency, the
mechanical findings of Cronin et al. (2012) and Csapo et al.
(2010) likely explain some of the muscular discomfort that habit-
ual HH wearers report when walking in flat shoes (Opila et al.,
1988). In particular, the triceps surae muscle fibres adapt to a
shorter length due to regular, long-term use of HH, and are there-
fore strained substantially when switching to flat shoes, even dur-
ing standing.
261
2. Effects of experience
Heel wearing experience is another controversial area, and most
studies have ignored its possible importance. Ebbeling et al. (1994)
found no effect of experience on heart rate, oxygen consumption or
lower limb mechanics. In this study, experienced wearers wore HH
3 or more times per week, 8 h per time, and the inexperienced
group wore them less than twice per month. Simonsen et al.
(2012) also reported no differences in lower limb joint moments
or EMG activity between experienced (1.5–7 times per week, mean
3.8 times) and inexperienced wearers (0–1 times per week, mean
0.5).
On the contrary, Barton et al. (2009) noted an earlier onset of
erector spinae muscle activity around heel strike after just two
days of habituation to heel lifts. In a study of 13–20 year old girls,
de Oliveira Pezzan et al. (2011) reported that inexperienced HH
users exhibited decreased lordosis and posterior pelvic tilt,
whereas experienced users showed the opposite trends. Opila-Cor-
reia (1990b) also reported ‘exaggerated upper trunk rotations’ and
smaller increases in knee flexion during stance in inexperienced
compared to experienced subjects. Gefen et al. (2002) noted that
peroneus longus and gastrocnemius lateralis were more vulnerable
to fatigue in women who regularly wore HH, contributing to de-
creased stability. They also observed an imbalance in EMG activi-
ties between the two gastrocnemius heads during fatigue in
habitual wearers.
Several factors must be considered when attempting to explain
the controversies in this area. Subject age is a potential contributor,
as age is known to influence balance and various aspects of neuro-
muscular function. Furthermore, few studies take into account the
height of heels worn by experienced subjects. It seems likely that
those experienced with higher heel heights show more obvious ef-
fects of habituation (see (Cronin et al., 2012; Csapo et al., 2010)),
whereas regular wearers of low heels (e.g. 2–3 cm) may not exhibit
obvious adaptations to chronic use, despite being classified as
experienced wearers. It is noteworthy that Cronin et al. (2012)
and de Oliveira Pezzan et al. (2011) both reported evidence of
chronic adaptations, presumably due to high heel use, in females
as young as 13–25. Thus frequent HH use can potentially induce
structural adaptations in some tissues over a much shorter time
course than previously assumed. Finally, it should be noted that
some parameters may be more affected by HH use than others,
so some of the apparent discrepancies between the studies out-
lined above may in fact just be due to parameters being measured.
There is a clear need for larger, more comprehensive comparisons
to determine whether this theory is correct, and if so, which
parameters and/or tissues are most affected by long-term HH use.
3. Methodological considerations
The most obvious limitation in this field is the small sample
size. Equivocal results have been presented in several areas, and
this may be partly due to differences in the characteristics of differ-
ent subject groups, e.g. anthropometric differences. Many studies
have only included around 10 women in the experimental group,
and group averaging these results may mask important physiolog-
ical information due to individual differences. Similarly, few stud-
ies have considered the effects of frequency and type of HH use,
and some studies have allowed participants to wear their own
shoes, whereas others have provided standardised shoes. The latter
may introduce subject-specific adaptations, and all of these param-
eters could increase heterogeneity within the test group, thus
again masking subtle physiological differences. Another issue is
the height of the heel relative to the length of the system it dis-
turbs, since a given heel height will shift the joint segments to a
262 N.J. Cronin / Journal of Electromyography and Kinesiology 24 (2014) 258–263
larger relative extent in a shorter individual (Cronin et al., 2012),
and thus a standardised heel height for all subjects may not be
appropriate. Body mass is another important parameter; for a gi-
ven foot size, a larger body mass would increase lower limb joint
pressures, which may in turn influence other parameters such as
force distribution within the foot.
Another limitation is the use of surface EMG electrodes in this
context. Since most studies examine both high and low heeled
(or barefoot) gait, muscle geometry is substantially altered be-
tween conditions, so the sample of motor units from which surface
electrodes record will differ. Therefore, comparisons of EMG ampli-
tudes between conditions rest on the assumption of homogeneous
spatial activation throughout the muscle, which may not be valid
in human walking and could thus produce minor non-physiologi-
cal differences. It is also noteworthy that most studies normalise
EMG data to that recorded during a maximal voluntary contrac-
tion. This invokes several issues such as variations in activation
strategies between trials (affecting the value used for normalisa-
tion), the ability to maximally contract an entire muscle group
(which may differ between individuals and muscle groups), effects
of motivation, and the optimal joint angle for maximal force pro-
duction (which likely varies between individuals). In addition,
some studies have either not normalised EMG data, or normalised
to a value other than that recorded during a maximal contraction,
making the comparison of some studies unreliable.
Some of the walking studies presented here were performed on
a treadmill. Numerous studies have compared walking on a tread-
mill versus more natural overground walking, with varying results.
Regarding the parameters of interest here, such as kinematics and
muscle activity, differences between the two test modes seem to
be small or non-existent, especially after a sufficient treadmill
adaptation period (Matsas et al., 2000). Nonetheless, studies com-
paring the two modalities were done in either barefoot or flat shoe
conditions, and it remains to be determined whether the two gait
modalities influence walking in HH differently. Clearly, larger stud-
ies are required that can control or at least account for the issues
presented here.
4. Future directions and conclusions
Despite variations in study methodology, subject characteristics
and the shoes being examined, HH generally cause qualitatively
consistent changes in the neuromechanics of walking. These
changes are widespread, affecting structures from the toes to the
spine, and mostly disadvantageous in terms of movement econ-
omy or increased risk of tissue damage. One avenue for future re-
search should be to attempt to quantify injury incidence in high
heel wearers, taking into account individual heel wearing habits.
This information is of vital importance because findings such as de-
creased movement economy due to HH have limited societal rele-
vance unless they can be linked to functional outcomes such as
fatigue or increased incidence of injury or falls.
It is important to note that some of the long-term effects of HH
summarised here are not necessarily the result of constant, high
forces. Most women who wear HH on a regular basis spend the
majority of their time sitting rather than walking, suggesting that
the change in foot position due to HH is a powerful stimulus to in-
duce tissue adaptations. Future research should aim to identify the
long-term neuromuscular adaptations that occur as a result of
wearing HH, as well as the parameters responsible for such adapta-
tions. It seems likely that at least shoe height and the duration and
frequency of use are important determinants of whether or not
adaptations occur, as well as the degree of adaptation. These issues
would ideally be examined with a comprehensive, long-term fol-
low-up design that controls for as many of the aforementioned
study limitations as possible. Once the key parameters affecting
high heeled gait and the associated neuromuscular and biomechan-
ical adaptations have been identified, we can begin to give accurate
recommendations about how to counter the negative effects of high
heels.
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Neil Cronin received his Ph.D. in Neuromechanics
from Aalborg University, Denmark in 2010. He then
worked as a Post-Doctoral researcher at Griffith
University in Australia. He is currently a Senior
Researcher at the University of Jyväskylä in Finland.
His research interests include various aspects of
human balance and locomotion, such as muscle–
tendon mechanics, neural control and movement
economy.