EFFECT ON PLANTAR PRESSURE DISTRIBUTION

WITH WEARING DIFFERENT BASE SIZE

OF HIGH-HEEL SHOES DURING WALKING

AND SLOW RUNNING

LAN-YUEN GUO*,§, CHIEN-FEN LIN*, CHICH-HAUNG YANG†,

YI-YOU HOU‡, HUNG-LIN LIU*, WEN-LAN WU*

and HWAI-TING LIN*

*Department of Sports Medicine, College of Medicine

Kaohsiung Medical University, Kaohsiung 807, Taiwan (R.O.C.)

†Department of Physical Therapy

Tzu-Chi University, Hualien 970, Taiwan (R.O.C.)

‡Department of Electrical Engineering, Far East University

Tainan 744, Taiwan (R.O.C)§yuen@kmu.edu.tw

Received 8 March 2011

Revised 6 June 2011

Accepted 12 June 2011

High heeled shoes may alter the regular loading pattern of the plantar pressure, especially

increased in the forefoot area. Walking with narrow base of high heeled shoes may induce the

brisk acceleration of the supported leg due to instability that increases the force on the plantar

area. Particularly, this phenomenon may be amplified while slow running, but never been

investigated. Materials and Methods: Plantar pressures were measured for different specific

area of foot using the Pedar-X system. The effects on plantar pressure with different sized bases

(1:2� 1:2 cm2 and 2:2� 3:5 cm2) of high-heeled shoe (7.8 cm in height) were examined while

walking in thirteen healthy female subjects and during slow running in nine healthy female

subjects. Results: The plantar pressures of the hallux and toe while wearing narrow base high

heel were significantly (p < 0:05) greater than those when walking with wearing wide base one.

For both narrow and wide base heels, significantly increased (p < 0:05) plantar pressure were

found in the medial forefoot while slow running at 2.0m/s as compared with walking at 1.0m/s

and 1.5m/s. While slow running with wearing narrow base high heel indicated significantly

(p < 0:05) increased plantar pressures in the medial, central and lateral forefoot and toes

regions compared with those with wearing wide base one. Conclusion: The findings suggest that

if individuals have to wear high heeled shoes, it would be better to select one with a wide based

heel to avoid running in at any circumstance.

Keywords: High heeled shoes; plantar pressure; walking; slow running; base width.

§Corresponding author.

Journal of Mechanics in Medicine and Biology

Vol. 12, No. 1 (2012) 1250018 (11 pages)

°c World Scientific Publishing Company

DOI: 10.1142/S0219519411004563

1250018-1

1. Introduction

High heels are one of the important features in the design of female shoes. Approxi-

mately 37%�69%of females oftenwore highheel shoes daily.1Females are encouraged

to wear high heel shoes due to the requirement of workplaces or fashion and with the

belief that their trunk will reveal a more graceful curvature. However, wearing high

heeled shoes for long timemay not only impair themusculoskeletal system around the

lower extremity and the torso, but also alter their gait pattern thus increasing the risk

of knee osteoarthritis.2�14 About 81.4% of females who wear high heel shoes reported

foot pain.15 However, wearing high heeled shoes seems to be a current global trend

and to extent some companies now believe that female workers should wear high heels

in order to show courtesy.15,16 Previous some studies have reported that wearing

high heeled shoes changes the biomechanical factors during walking,17�20 such as

changes in the loading pattern of lower extremity20 and increases in the plantar

pressure, especially in the forefoot area.17,19,21,22 Other studies showed that wearing

high heeled shoes was associated with higher arches of the foot, changes in gait pat-

tern, decreased pressure on the middle foot and increased pressure on fore-

foot,4,15,17,23,24 these changesmay contribute to foot pain or increase the discomfort of

the foot. While wearing high heeled shoes, the plantar pressure would shift from the

areas of 3rd, 4th, and 5thmetatarsal head to 1st, and 2ndmetatarsal head.17,19,22,24,25

As expected, the ground reaction force is much bigger while running than walking.

Some research have indicated that the vertical ground reaction force increases to

about 2.5�2.8 times of body weight (BW) while running26,27 compared with 1.0�1.2

times of BW while walking. It has been reported that running causes higher plantar

pressure than walking, and thus running injuries result.27�29 Wearing high heeled

shoes will increase plantar pressure while walking, whereas during running, this may

induce greater plantar pressure for higher risk of foot injuries. There is little research

on whether the plantar pressure pattern changes while running compare to walking

when wearing high heeled shoes.

Previous research has shown that wearing high heeled shoes may alter the

loading pattern of the plantar pressure, especially increased in the forefoot

area.17,19,22,24,25 However, the effect of different design of the high heel such as the

base size of high heel was rarely investigated. Walking with narrow base of high

heeled shoes may induce the increased acceleration of the supported leg due to

instability that raise the force on the plantar area. Particularly, these changes may

be amplified while slow running and need further investigation. The purposes of this

study were to confirm that different base size of heels influence plantar pressure

during walking, and to compare the plantar pressures in walking and slow running.

2. Methods

2.1. Experimental procedure

This experiment was divided into two parts, (1) effects on plantar pressure while

walking in high-heel shoes of different sized bases; (2) the influence on the plantar

L.-Y. Guo et al.

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pressure pattern during slow running. Individuals were excluded if there was a

history of lower extremity musculoskeletal injury or neurologic disorder within the

last six months. The in-sole plantar pressure measurement Pedar-x system (Novel,

GmbH, Munich, Germany) was used to quantify foot pressure of eight regions

(masks) as defined in the Novel Groupmask Evaluation software (Pedarr-x, Novel

Co., Germany). The regions include heel (MO1), medial midfoot (MO2), lateral

midfoot (MO3), medial forefoot (MO4), central forefoot (MO5), lateral forefoot

(MO6), hallux (MO7) and toes (MO8) (Fig. 1). Previous studies showed that in-sole

plantar pressure measurement were repeatable and this system could measure the

contact area, peak pressure and pressure-time integral in small area.30,31 The high

heeled shoes were 7.8 cm in height and the sizes of narrow and wide base were

1:2� 1:2 cm and 2:2� 3:5 cm, respectively (Fig. 2).

(1) Effects on plantar pressure while walking in different sized bases of high-heeled

shoes.

Thirteen healthy female volunteers (mean age 22 years (SD: 0.8)) were recruited.

Subjects were asked to walk at a cadence of 96 steps per minute by metronome in

different sized bases of high-heeled shoes. After familiarization with the walking

Fig. 1. The mask definition of the plantar area. MO1: Heel, MO2: Medial midfoot, MO3: Lateral

midfoot, MO4: Medial forefoot, MO5: Central forefoot, MO6: Lateral forefoot, MO7: Hallux, MO8: Toes.

(a) (b) (c)

Fig. 2. The different base sizes of high-heeled shoes and high heeled.

Effect on Plantar Pressure Distribution with Wearing High-Heel Shoes

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speed, we collected foot pressure data for a variety of types of shoes for at least three

times to obtain the average.

(2) The influence on the plantar pressure pattern during slow running.

Nine healthy female volunteers mean age was 21 (SD: 0.4) years old were

recruited. Subjects were required to wear a variety of types of shoes and instructed

to walk at two selected speeds (1.0m/s and 1.5m/s) and slow running (2.0m/s)

these speed control by monitor on the treadmill.

2.2. Statistical analysis

Novel Groupmask Evaluation software (Pedarr-x, Novel Co., Germany) was used

to determine the peak plantar pressure in the various areas of foot. Repetitive

measurement analysis of variance (ANOVA) was used to determine difference in

peak planter pressure of different shoe designs and gait speed using the Tukey’s post

hoc test. Significance level was set as p < 0:05, and SAS 8.0 statistical software (SAS

Institute Inc., North Carolina, USA.) was used.

3. Results

3.1. For high-heel shoes with different base size during walking

Our study showed that plantar pressure transferred from the heel towards the

forefoot while wearing the casual shoe (Table 1, Fig. 3). The plantar pressure

in areas of heel (MO1), medial midfoot (MO2) and lateral midfoot (MO3) with

wearing narrowed based heels and wearing wide based heels were significantly

smaller (p < 0:05) than that wearing casual shoes respectively.

The plantar pressure patterns changed with the different heels of various base

widths (Table 1). The plantar pressure of the medial forefoot (MO4) with wearing

narrowed based heels (321.2 kpa) and with wearing wide based heels (312.9 kpa) was

significantly greater (p < 0:05) greater than when wearing casual shoes (225.5 kpa).

The plantar pressure of the hallux (MO7) with wearing narrowed based heels

(286.6 kpa) was significantly greater (p < 0:05) than that when wearing wide based

heels (255.7 kpa). Both plantar pressures were greater than when wearing casual

shoes (177.3 kpa). The plantar pressure of the toe (MO8) with wearing narrowed

based heels (114.3 kpa) was significantly greater (p < 0:05) than that when wearing

wide based heels (97.7 kpa). Both plantar pressures were greater than when wearing

casual shoes (81.0 kpa).

3.2. For high-heeled shoes with different

sized bases during slow running

With wearing the narrow based high heel and walking at different speeds, plantar

pressure increased in all areas of the foot at the speed of 2.0m/s compared to 1.0m/s

and 1.5m/s (Table 2). The plantar pressure of the medial forefoot (MO4) with

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(a) Narrow (b) Wide (c) Casual

Fig. 3. The peak pressure at different base sizes of high-heeled shoes and high heeled.

Table 1. Peak pressure comparison of narrow and wide based heels

and casual shoe.

Narrow Wide Casual F value Post Hoc

TO 359.7 334.4 253.6 7.97**

(79.8) (77.4) (62.3)

He(MO1) 154.8 165.3 184.5 7.41**

(32.8) (32.4) (31.7)

LM(MO2) 54.8 54.3 94.2 3.80*

(44.0) (41.3) (48.6)

Mm(MO3) 77.0 86.4 128.2 18.69**

(20.6) (19.3) (41.7)

MF(MO4) 321.2 312.9 225.5 6.74**

(82.7) (78.1) (80.4)

CF(MO5) 241.6 243.3 213.1 1.11

(89.3) (70.3) (35.6)

LF(MO6) 170.2 167.7 185.3 0.51

(66.0) (61.0) (40.3)

Ha(MO7) 286.6 255.7 177.3 4.77*

(115.1) (90.0) (68.2)

To(MO8) 114.3 97.7 81.0 3.88* N > W > C

(38.7) (34.6) (32.0)

Note: aHe(MO1): Heel, LM(MO2): Lateral midfoot, Mm(MO3):

Medial midfoot, MF(MO4): Medial forefoot, CF(MO5): Central

forefoot, LF(MO6): Lateral forefoot, Ha(MO7): Hallux, To(MO8):

Toesb* p < 0:05; **: p < 0:01

Effect on Plantar Pressure Distribution with Wearing High-Heel Shoes

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walking at speed of 1.0m/s (426.0 kpa) was significantly smaller (p < 0:05) than

that walking at speed of 1.5m/s (521.3 kpa) when wearing narrowed based

high heels. Both plantar pressures were smaller than that slow running at speed of

2.0m/s (579.9 kpa)with wearing narrowed based high heels.

For the wide based high heel, plantar pressure increased in all areas of the foot

during walking at 2.0m/s compared with 1.0m/s and 1.5m/s, with significant

increases shown especially in the lateral midfoot (MO3) and the medial forefoot

(MO4). The plantar pressure of the medial forefoot (MO4) with walking at speed of

1.0m/s (421.3 kpa) was significantly smaller (p < 0:05) than that walking at speed

of 1.5m/s (507.3 kpa) when wearing wide based high heels. Both plantar pressures

were smaller than that slow running at speed of 2.0m/s (531.0 kpa) with wearing

wide based high heels. The plantar pressure of the lateral midfoot (MO3) with

walking at speed of 1.0m/s (76.3 kpa) was significantly smaller (p < 0:05) than that

walking at speed of 1.5m/s (95.1 kpa) when wearing wide based high heels. Both

plantar pressures were smaller than that slow running at speed of 2.0m/s

(106.3 kpa) with wearing wide based high heels.

Plantar pressure when wearing the narrow high heel were greater in most areas

of the foot than with wearing wide high heel while slow running at the speed of

Table 2. Peak pressure during slow running and walking with high-heels of

narrow based shoes.

1.0 m/s 1.5 m/s 2.0 m/s F value Post Hoc

TO 444.9 524.5 579.9 3.276* S1<S2<S3

(122.4) (84.4) (84.4)

He(MO1) 176.0 182.5 187.0 0.079

(38.2) (45.9) (45.9)

LM(MO2) 116.2 132.5 149.2 0.318

(68.3) (63.1) (63.1)

Mm(MO3) 99.1 119.5 131.4 0.874

(33.7) (43.1) (43.1)

MF(MO4) 426.0 521.3 579.9 3.891* S1<S2<S3

(131.1) (88.1) (88.1)

CF(MO5) 247.5 261.6 344.2 1.459

(107.1) (99.6) (99.6)

LF(MO6) 160.1 156.1 206.3 0.545

(83.5) (67.5) (67.5)

Ha(MO7) 250.0 266.2 342.6 1.781

(115.3) (137.7) (137.7)

To(MO8) 124.3 146.0 176.0 1.315

(38.8) (61.6) (61.6)

Note: aHe(MO1): Heel, LM(MO2): Lateral midfoot, Mm(MO3): Medial mid-

foot, MF(MO4): Medial forefoot, CF(MO5): Central forefoot, LF(MO6):

Lateral forefoot, Ha(MO7): Hallux, To(MO8): Toesb*p < 0:05cUnit: KpadS1: 1.0m/s, S2: 1.5m/s, S3: 2.0m/seNarrow high heeled plantar pressure were greater than wide high heeled

L.-Y. Guo et al.

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2.0m/s. Notably, this increase reached significant difference (p < 0:05) in the

forefoot (MO4-MO6) and toes (MO8).

4. Discussions

Our study showed that when walking cadence was kept constant, wearing high heel

shoe was associated with increased plantar pressure in the medial forefoot, hallux

and toe regions compared with wearing casual shoe. In addition, wearing narrow

based high heel was associated with greater plantar pressure especially in the hallux

and toe regions than those wearing wide based high heels. The other important

finding is that while wearing high heeled shoes, plantar pressure increased with the

walking speed increased and affecting the medial forefoot area more dramatically.

While slow running, the plantar pressure increased in all areas of the foot during a

gait as compared to walk. Wearing the narrow high heel and slow running, plantar

pressure in forefoot and toes regions were greater than those slow running with

wearing wide high heel.

The results are consistent with previous studies in that high heeled shoes

causes an increase in plantar pressure of the medial forefoot, however, less study

point out the effects on the regions of hallux and toe. Medial forefoot is around

first metatarsophalangeal (MTP) joint and the stability of first MTP joint is

provided by a capsuloligamentous soft tissue structure.22,32,33 Since medial

structures of first MTP are more unstable and the lateral structures including the

capsular and collateral ligament are relatively tight, there is a high possibility

that hallux valgus occurred during inappropriate loading.22 When wearing high

heels and in a standing position, the hallux would be in a more hyperextended

position. As this is a relative loose pack position, joint stability is decreased. The

increase in medial forefoot plantar pressure will lead to movements of the MTP

towards the medial and dorsal direction, which may fasten the occurrence of

hallux valgus.22 Furthermore, previous studies have shown that peak pressure in

the first MTP joint may accumulate, which may contribute to fatigue fracture.22

In this study, we found wearing high heel shoe was associated with increased

plantar pressure in the hallux, it was only a little less than that in the medial

forefoot.

The use of insoles to reduce problems of the foot during gait with high heeled

shoes has been explored,15,34 but less focus on reducing the pressure in hallux, an

area secondary to the plantar pressure of medial forefoot while wearing high heel

shoe. Lee et al. studied the impact of different insoles while wearing high heels and

found that inserts with total contact could provide a greater effect in reducing

plantar pressure as compared to inserts for the forefoot alone.34�37 It is concluded

that total contact insert may improve more comfort than heel cups or arch support

only alone. Another study used metatarsal pads to decrease forefoot pressure by

transferring the sustained force to the longitudinal and metatarsal arch.15 However,

Effect on Plantar Pressure Distribution with Wearing High-Heel Shoes

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some studies found that metatarsal pads can transfer load from the forefoot to

midfoot, but the plantar pressure around forefoot was not changed significantly.

Further development of the insole design to reduce the plantar pressure in the hallux

area may helpful to increase the comfort while wearing high heel shoe.

In the current study, we use the analysis of peak pressure since it is much related

to the subjective feeling of comfort.35 However, there are other parameters (such as

plantar force, integrals of the pressure-time and force-time, contact area, and power

ratio) may be useful for plantar pressure analysis, as listed in Table 3. Plantar

pressure assessment is a convenient measurement which is portable and assesses

plantar pressure for several sites, in addition, it was revealed that the possible usage

of frequency domain analysis like power ratio for examine the uniformity of pressure

distribution over defined plantar region.39

5. Conclusion

The results of our study showed that wearing narrow based high heels cause greater

plantar pressure in medial forefoot than wearing wide based high heels. In addition,

Table 3. Comparison of different parameters for analysis of plantar pressure.

Parameters Definition Units Description

Peak Pressure The maximum pressure value

in a specific plantar area

during walking period. The

magnitude of pressure was

calculated from the

measured force by the area

of the insole

N/cm2 or Kpa It can be use to characterize the

loading variation between the

different plantar region.

Mostly related to the sub-

jective feeling of comfort

Plantar Force The highest force in a specific

plantar area during walking

period

N It cannot be used for comparison

of the maximum force between

regions due to variations in

each plantar region. However,

it could be used to compare

loading between variations

in the different walking

condition

Integrals (or

Impulse) of

the Pressure-

Time and

Force-Time

It was defined by the area

beneath the pressure-time

curve and the force-time

curve

Kpa-s/

N-s

The time effect can be took into

consideration.

Contact Area It was referred to the amount of

surface contact between the

surface of the plantar aspect

of foot and the sensor

cm2 It can be used to determine if the

raised pressure come from the

increased force or decreased

contact area

Power Ratio The ratio of the high frequency

to the total power

None It can be used to examine the

uniformity of pressure distri-

bution over defined plantar

region in a specific time event

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the plantar pressure around the medial forefoot area was increased when the gait

speed increased. Thereafter, it would be suggested that if you have to wear high

heeled shoes, it will be better to select one with a wide based heel and to avoid

running in at any circumstance. Further study may suggested to investigate the

long term effect of wearing wide based high heels and the development of insole

application specified for wearing narrow based high heels even in the situation of

slow running. Frequency domain analysis may also be considered to apply to this

current study.

Acknowledgment

This work is supported by Nation Science Council NSC 97-2629-E-037-001, Taiwan.

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