The influence of heel height on patellofemoral joint kinetics during walking
Highlights
► The purpose of this study was to determine if heel height increases patellofemoral joint loading during walking. ► Patellofemoral joint stress was found to increase with increasing heel height. ► The increased patellofemoral joint stress was driven mainly by an increase in patellofemoral joint reaction force. ► This finding suggests that wearing high-heeled shoes may be associated with the development of patellofemoral pain. ► Heel height should be taken into consideration while prescribing footwear for individuals with patellofemoral symptoms.
Introduction
Patellofemoral pain (PFP) is one of the most common disorders of the lower extremity, accounting for 25% of all knee injuries treated in orthopedic clinics [1], [2]. In addition, PFP has been shown to be more common in women compared to men [3]. It has been proposed that PFP may be the result of increased patellofemoral joint stress, which is defined as the patellofemoral joint reaction force per unit area of contact of the patella against the femur [4].
Wearing high-heeled shoes has long been considered a potential risk factor for the development for PFP in women [3]. Previous studies have shown that high-heeled gait increases the knee flexion angle during the loading phase of gait [5], which could lead to an elevated knee extensor moment and patellofemoral joint reaction force. Saunders et al. [5] suggest that exaggerated knee flexion is needed during loading response to compensate for the loss of ankle dorsiflexion caused by the wearing of high-heeled shoes.
Apart from the patellofemoral joint reaction force, patellofemoral joint contact area also has been shown to vary with the knee flexion angle. Powers and colleagues [6] have reported that patellofemoral joint contact area increases linearly from 0 to 30 degrees of knee flexion, remains unchanged from 30 to 60 degrees, and decreases slightly from 60 to 90 degrees of knee flexion. Therefore, greater knee flexion angles during loading response while wearing high-heeled shoes may result in greater contact area, and potentially offset any increase in patellofemoral joint reaction force. However, Goudakos et al. [7] have reported that the regulatory influence of increasing contact area to protect against high patellofemoral pressure is exhausted at relatively low loads. Therefore, an elevated patellofemoral joint reaction force has been suggested to be the key determinant with respect to the increased patellofemoral joint stress [7].
To date, a thorough understanding of how high-heeled gait influences patellofemoral joint kinetics is lacking. Using a previously described patellofemoral joint model, the purpose of this study was to determine if heel height increases patellofemoral joint stress during walking. A secondary purpose was to identify the kinematic and kinetic variables that may explain patellofemoral joint stress differences when wearing shoes with varied heel heights.
Section snippets
Subjects
Eleven healthy, pain-free women participated in this study. The average age, height and weight of the study participants were 25.0 yrs (SD 3.1), 161.6 cm (SD 5.4), and 55.5 kg (SD 7.1), respectively. Participants who reported any current orthopedic injury or medical condition that prevented normal ambulation were excluded from participation. All subjects had prior experience wearing high-heeled shoes and were current casual wearers. On average, subjects reported wearing high heels 5.0 times a
Patellofemoral joint stress
Across the 3 heel height conditions, the peak patellofemoral joint stress occurred at the end of loading response (i.e., approximately 20% of stance phase; Fig. 3). The ANOVA comparing peak patellofemoral joint stress among the 3 shoe conditions was significant (p = 0.002; Table 1). Post hoc testing revealed the peak patellofemoral joint stress during the high heel condition) was significantly greater than both the medium heel (p = 0.000) and low heel (p = 0.001) conditions. Additionally, the peak
Discussion
The primary purpose of the current study was to determine if heel height increases patellofemoral joint stress during walking. On average the high heel condition resulted in a significant increase in peak patellofemoral joint stress (89.5%) compared to the low heel condition. When compared to the medium heel condition, a 38.5% significant increase in patellofemoral joint stress was observed. As such, our findings support the premise that wearing high-heeled shoes may be a risk factor with
Conclusion
Increasing heel height increases peak patellofemoral joint stress during walking. The increased patellofemoral joint stress was driven mainly by an increase in patellofemoral joint reaction force. This finding suggests that wearing high-heeled shoes may be associated with the development of PFP. As such, heel height should be taken into consideration while prescribing footwear for individuals with patellofemoral symptoms.
Acknowledgments
The authors thank Dr. Chatchada Chinkulprasert for her assistance in data processing.
Conflict of interest statement
The authors have no conflict of interest to disclose for this research.
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