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Applied Ergonomics 36 (20
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Abstract
and shifts peak pressures from the third, fourth and fth
Clark, 1985; Snow et al., 1992; Eisenhardt et al., 1996).
employment criteria and/or fashion customs encouragedthe
continuous use of high-heeled shoes. Studying theimpact of high
heels on kinetic changes and perceived
ARTICLE IN PRESSdiscomfort provide a basis for designs that
minimizeadverse effects.
0003-6870/$ - see front matter r 2005 Elsevier Ltd. All rights
reserved.
doi:10.1016/j.apergo.2004.11.001
Corresponding author. Tel.: +886 2737 6339; fax: +8862737
6344.E-mail address: [email protected] (L. Yung-Hui).Surveys of
shoe choice have shown that 3769% ofwomen wear high-heeled shoes on
a daily basis (TheGallup Organization, 1986; Frey et al., 1993).
Wearinghigh-heeled shoes modies gait kinematics and
kinetics(Esenyel et al., 2003; Snow et al., 1992; Mandato
andNester, 1999; Voloshin and Loy, 1994; Kerrigan et al.,1998).
Previous studies have demonstrated that walkingin high-heeled shoes
alters lower-extremity joint func-tion (Esenyel et al., 2003),
raises the peak pressure in theforefoot (Snow et al., 1992; Mandato
and Nester, 1999),
In addition, wearing high-heeled shoes for walkinggenerates a
force spike at the initial ground contact (i.e.,impact force) and
the force is then transmitted upto the skeleton as a shock wave
(Voloshin and Loy,1994). This shock wave appeared to damage soft
tissues,which may result in leg and back-pain complaints(Wosk and
Voloshin, 1981; Voloshin and Wosk, 1982)and eventually lead to
degenerative joint disorders(Kerrigan et al., 1998). Despite
concerns regarding theiradverse effects on human musculoskeletal
system,minimize the adverse effects on the human musculoskeletal
system. Previous studies demonstrated the effects of inserts on
kinetics
and perceived comfort in at or running shoes. No study attempted
to investigate the effectiveness of inserts in high heel shoes.
The
purpose of this study was to determine whether increasing heel
height and the use of shoe inserts change foot pressure
distribution,
impact force, and perceived comfort during walking. Ten healthy
females volunteered for the study. The heel heights were 1.0 cm
(at), 5.1 cm (low), and 7.6 cm (high). The heel height effects
were examined across ve shoe-insert conditions of shoe only; heel
cup,
arch support, metatarsal pad, and total contact insert (TCI).
The results indicated that increasing heel height increases impact
force
(po0:01), medial forefoot pressure (po0:01), and perceived
discomfort (po0:01) during walking. A heel cup insert for
high-heeledshoes effectively reduced the heel pressure and impact
force (po0:01), an arch support insert reduced the medial forefoot
pressure,and both improved footwear comfort (po0:01). In
particular, a TCI reduced heel pressure by 25% and medial forefoot
pressure by24%, attenuate the impact force by 33.2%, and offered
higher perceived comfort when compared to the non-insert
condition.
r 2005 Elsevier Ltd. All rights reserved.
Keywords: High-heeled shoes; Insert; Impact force; Pressure
distribution
1. Introduction metatarsal heads to the rst and second (Soames
andStudying the impact of high-heeled shoes on kinetic changes and
perceived discomfort provides a basis to advance the design
andEffects of shoe inserts and heel heand perceived com
Lee Yung-Hui
Department of Industrial Management, National Taiwan U
Sec IV, Taipei
Received 26 January 200405) 355362
t on foot pressure, impact force,rt during walking
ong Wei-Hsien
sity of Science and Technology, No. 43, Kee-Lung Road,
an, 106 ROC
epted 12 November 2004
www.elsevier.com/locate/apergo
-
Engineering efforts to reduce foot loading caused bypeak
pressure and impact force, and to improve shoecomfort, involved
designing shoe inserts with differentshapes (Light et al., 1980;
Chen et al., 1994; Hodge et al.,1999; Lee et al., 2004). The use of
inserts is effective inredistributing the pressure beneath the foot
andabsorbing energy in terms of reducing impact force.Various inert
designs demonstrate different kineticmodication during gait. For
example, a heel pad iseffective in reducing heel pressure and the
magnitude ofthe heelstrike impact (Light et al., 1980; Jorgensen
andEkstrand, 1988). An arch support was designed to
resistdepression of the foot arch during weight bearingthrough
skeletal support, thereby decreasing tensionin the plantar
aponeurosis (Kogler et al., 1996). Ametatarsal pad has been found
to reduce forefootpressure and transfer weight bearing to the
longitudinaland metatarsal arches (Lee et al., 2004). Finally, a
totalcontact insert (TCI) provided pressure relief in the heeland
forefoot regions (Lord and Hosein, 1994; Chenet al., 2003). These
studies, however, focused on insertsin at or running shoes. No
study, insofar as we haveexamined, attempted to identify insert
effectiveness in
2. Methods
2.1. Participants and materials
Ten healthy females volunteered for this study. Theaverage age
of the subjects was 23 years (range 2028),average weight was 50 kg
(range 4753), and averageheight was 160 cm (range 156162). None of
the subjectshad suffered an injury to the lower extremity during
thepreceding year. Four subjects had worn high-heeledshoes
two-to-ve times per week for at least 1 year. Theother six had
relatively limited experience. Writtenconsent was obtained from
each subject before com-mencement of the experiment.The shoes used
in this study were commercially
available items and were selected based on the similarityof
construction such as foot contact points, supports,and pump style.
The main difference among these shoeswas the height of the heel: a
at (1.0 cm), a low (5.1 cm)and a high heel (7.6 cm) (Fig. 1). The
mediolateral byanteroposterior dimensions of the heel of the shoes
wereas follows: 2.8 3.0 cm and 2.4 2.6 cm (low and highheel,
respectively). Each participant received ve insert
ARTICLE IN PRESS
. Fro
L. Yung-Hui, H. Wei-Hsien / Applied Ergonomics 36 (2005)
355362356high heels.The purpose of this study was to determine
whether
increasing heel height and the use of various types ofshoe
inserts would result in changes in foot pressuredistribution,
impact force, and perceived comfort duringwalking. The types of
shoe inserts used in the currentstudy included heel cup, arch
support, metatarsal pad,and TCI.
Fig. 1. The shoes of three different heel heights were used in
this studyFig. 2. The custom-made insertsconditions: (1) shoe only;
(2) heel cup; (3) arch support;(4) metatarsal pad; and, (5) TCI
(Fig. 2).The inserts were custom fabricated for each indivi-
dual. The fabricating steps were: (1) negative impressionof foot
using Hydrogum alginate (Zhermack, SPA,Italy) set while the subject
was wearing the high-heeledshoes in seating posture; (2) producing
a positive cast ofthe feet by pouring plaster into the high-heeled
shoes;
m left to right: a at (1.0 cm), a low (5.1 cm) and a high heel
(7.6 cm).and their support positions.
-
and, (3) making semi-rigid inserts from Multiformmolded
materials (AliMed Inc., Dedham, MA) thatwere contoured from the
individual positive casts.Multiform is a thermoformable
cross-linked polyethy-lene foam. The density of multiform provides
goodsupport as well as cushioning (Lamb, 1991). To preventa tight
feeling in the toe box, the TCI was designedto terminate at the
distal border of the metatarsalheads (see Fig. 2). To avoid
slipping around the inside ofthe shoe, the inserts were adjusted to
appropriateposition and then attached inside the shoe while
beingworn.
2.2. Apparatus
Pressure distributions were measured using the Pedar
ARTICLE IN PRESSL. Yung-Hui, H. Wei-Hsien / Appliedin-shoe
pressure measurement system (Novel GmbH,Munich, Germany) (Fig. 3).
The Pedar system consistsof A/D conversion electronics housed in a
small unitattached to the subjects waist. Leads to each
99-sensorinsole (sample rate 50Hz) were connected to A/Dconversion
electronics linked to a computer. Thepressure-measuring insole has
a linear response toapplied loads of 050N/cm2 with minimal error,
andno interference to normal gait characteristics has
beendemonstrated (McPoil et al., 1995). A description of thePedar
system and components have been previouslyreported (McPoil et al.,
1995; Barnett et al., 2001). Formeasuring impact force external to
the shoe, two AMTIforce plates (Model OR6-5-1000; Advanced
Biomecha-nical Technology, Newton, MA) were installed on thewalkway
(960Hz sampling rate). The Novel playersoftware (Novel GmbH,
Munich, Germany) synchro-nized foot-pressure data with video and
force-plates.The player is made for effortless synchronized
playback,presentation or analysis of complex dynamic events.Fig. 3.
The Pedar in-shoe pressure measurement system.2.3. Comfort
measurement
The visual analogue scale (VAS) developed byMunermann et al.
(2002) was a reliable measure toassess footwear comfort. The VAS
was used to rate thefootwear comfort for each experimental
condition inthis study. Comfort was rated by a ruler that
consistedof a 100mm VAS with the left end of the scale labelednot
comfortable at all (0 comfort point) and the rightend labeled the
most comfortable condition imaginable(10 comfort points). To
perceive uniform comfortableexperiences, we required participants
to comfortably tinto the size and advised them not to take the
effects ofshoe cosmetics and styles into comfort rating.
2.4. Procedures
In the study, all participants walked on a treadmill forwarm up
and walked on a level walkway for datacollection. Firstly, each
participant walked on a tread-mill for 5min at 130 cm/s to become
habituated to eachheel height and walking speed. The speed of 130
cm/swas used because walking speed may inuence plantarpressure and
ground reaction force (Schwartz et al.,1964; Murray et al., 1970).
The comfortable speedsreported in previous studies about high heels
rangedfrom 122 to 140 cm/s (Opila-Correia, 1990; Snow andWilliams,
1994; Esenyel et al., 2003).A split plot design was used in the
study. Firstly, a
heel height was randomly assigned to the participant.For the
same heel height, the order of inserts was thenrandomly selected.
To prevent fatigue, each participanttook a 5-min rest in between.
Data of three successfultrials were collected. The gait initiation
and terminationphases were recorded and only the middle gait cycle
wasused for analysis to each trial. A total of 450 trials
(10subjects 3 heel heights 5 insert conditions 3 trials)were
obtained for data analysis.
2.5. Data analysis
Novel Multimasks analysis software (Novel Electro-nics, Inc.)
was used to calculate the peak plantarpressure, at the region of
highest pressure during gaitcycle, for the six foot regions: heel,
midfoot, lateral andmedial forefoot, toes, and hallux (big toe).
The regionwas dened based on a percentage of the width and
thelength of foot (Fig. 4A). A LabView (National Instru-ments,
Austin, TX, US)-based program using a low-passlter with a cut-off
frequency of 400Hz (Gillespie andDickey, 2003) was written to
analyze ground reactionforce. Impact force obtained from ground
reaction forcewas a force spike superimposed on the upslope of
theinitial ground-reaction peak occurring right after theheelstrike
(Whittle, 1999) (Fig. 4B). Impact force was
Ergonomics 36 (2005) 355362 357normalized to body weight (%BW).
As described by
-
trials that showed the highest repeatability were chosen
ARTICLE IN PRESS
GRF
(%BW
)
80
1
1
1
(B)
rface
pliedfor averaging. All subsequent analyses were derivedfrom
these averaged data sets.Analysis of variance (ANOVA) was employed
to
study the effects of heel height and shoe insert. TukeysHSD test
was used for post hoc comparison. To test forrelationships between
comfort rating and pressure andimpact-force variables, Pearsons
correlation coefcientswere calculated. An alpha level of 0.01 was
used for alltests of statistical signicance to minimize the
experi-ment-wise error rate.
3. Results
The assumption of homogeneity is examined and notviolated. Fig.
5 illustrates the comparisons of peakpressures in different foot
regions and Table 1 lists theKadaba et al. (1989), a statistical
assessment of thebetween-trial repeatability was performed by using
thecoefcient of multiple correlations for each motionpattern per
participant for each condition. Repeatabilitywas high between
trials for each participant, the three
Heel
(A)
Midfoot
Me forefoot
Medi forefoot
Lateral forefoot
85%
58%
31%
0%
40%50%0% 100%
Medial
Medial forefoot
Fig. 4. (A) Denition of the six plantar-su
L. Yung-Hui, H. Wei-Hsien / Ap358comparisons of impact forces
for each test condition.ANOVA results indicated a signicant heel
height effecton peak pressure of the medial forefoot (F 2;18
42:6;po0:01), the heel (F 2;18 51:2; po0:01), and themidfoot (F
2;18 16:3; po0:01) regions, and impactforce (F 2;18 64:4; po0:01).
Post hoc comparisonsusing Tukeys HSD test showed a signicantly
higherpeak pressure in the medial forefoot region during
high-heeled walking. On the contrary, peak pressure in theheel and
the midfoot regions decreased as the heel heightwas increased. The
impact force in high heel wassignicantly higher than in low heel
and at shoes.ANOVA results also indicated a signicant insert
effect on peak pressure of the medial forefoot (F 4;36 25:6;
po0:01), the heel (F 4;36 24:8; po0:01), and themidfoot (F 4;36
12:6; po0:01) regions, and impactforce (F 4;36 8:6; po0:01). Post
hoc comparisonsshowed that peak pressure in the heel region
wassignicantly reduced with the use of heel cup and TCIthan that
with the use of metatarsal pad and shoe onlyin all heights. In the
midfoot region, the peak pressurewas increased with the use of arch
support, metatarsalpad, and TCI compared to the use of the heel cup
andshoe only. In medial forefoot region, the peak pressurewas
decreased with the use of arch support and TCIcompared to the use
of shoe only, and peak pressurewith the use of TCI was also
signicantly lower thanthat with the use of metatarsal pad in low
and high heel(Fig. 5). The impact force was effectively
attenuatedwith the use of heel cup and TCI compared to the use
ofshoe only in all heights. Impact force with a use of TCIwas also
signicantly lower than that with a use ofmetatarsal pad in high
heel (Table 1).Fig. 6 illustrates the comparisons of comfort
ratings
for each test condition. ANOVA results indicated asignicant heel
height (F 2;18 46:8; po0:01) and insert(F 4;36 30:4; po0:01)
effects for the comfort rating.Post hoc comparisons showed that
comfort rating wassignicantly decreased with an increase of heel
height.The comfort rating with the use of TCI was higher than
0
20
40
60
30 40 50 60 70Stance phase (%GC)20100
Impact forceImpact force
regions; (B) vertical ground reaction force.00
20
40 First peak vertical forceFirst peak vertical force
Ergonomics 36 (2005) 355362that with the use of metatarsal pad
and shoe only in allheights, and the rating with the use of heel
cup and archsupport were higher than that of the shoes only in
lowand high heel.Table 2 lists the coefcients of correlation
between
measures of biomechanical variables and comfort rating.The
comfort ratings were signicantly correlated (po0:01)with peak
pressure in medial forefoot (0.601), in themidfoot (0.356), and
impact force (0.369).
4. Discussion
The results supported our hypotheses that increasingheel height
would change pressure distribution under theplantar surface and
increased impact force and per-ceived discomfort during walking.
All inserts were
-
ARTICLE IN PRESSplied25
3035
(N/cm
2 )
Heelp
-
ARTICLE IN PRESSplied0
2
4
Com
fort
ratin
g
6
8
10
Flat shoe Low heel High heel
TCI
p
-
heels, indicating that higher heel lift might lead to more
vertical force and temporal parameters produced by an
in-shoe
pressure measuring system and a force platform. Clin. Biomech.
16
height on forefoot loading. Foot Ankle 14 (3), 148152.
Eisenhardt, J.R., Cook, D., Pregler, I., Foehl, H.C., 1996.
Change in
temporal gait characteristics and pressure distribution for bare
feet
ARTICLE IN PRESSplieddiscomfort. VAS provided a reliable measure
to assessfootwear comfort, as indicated in a previous
study(Munermann et al., 2002). This was true for
high-heeledambulation, as previous ndings indicate that mostpeople
can rapidly distinguish between comfortable anduncomfortable
footwear (Munermann et al., 2001). Themechanism underlying this
perception and the function-ing of the feedback control system are
not clearlyunderstood. Our comfort ratings were, however,
nega-tively correlated with peak pressure in the medialforefoot (r
0:601) and impact force (r 0:369),but were positively correlated
with peak pressure in themidfoot (r 0:356; po0:01). It appears
reasonable tosuggest that our participants were able to perceive
theextent of the comfort through realization of the changesin
pressure distribution and impact force that character-ized the
different inserts. The study indicated that theuses of some inserts
were effective in improving comfortwhen wearing high-heeled shoes.
In comparison withnon-insert shoes, the use of a heel cup improved
comfortrating from 2.6 to 5.2, an arch support to 5.4, and a
TCImore to 6.8. Therefore, the TCI offered superiorcomfort compared
to non-insert condition when wear-ing high-heeled shoes.There are
several limitations to the current study.
First, the experience of wearing high heels might be
aconfounding factor in response to the experimentalconditions.
Several subjects had limited experience usinghigh heels. In
addition, this study was laboratory-basedand the tasks were
preformed over a 2-h period. In arealistic work environment, the
individual may bestanding for much of the work day. An experiment
oflonger duration may provide better insight into thebehavioral and
physical adaptations of each individualand reect the effects found
in real work environments.Second, when examining pressures at the
footshoeinterface using an insert as a measuring device, the
factthat the presence of the insert itself could inuence
theseparameters must not be neglected. There is no directway of
measuring this. Therefore, the recorded pressuremay have small
errors which are inevitable. However,participants perceptions of
changes in comfort pro-duced by the insertion of the insole may
give someindication of pressure distribution changes.
5. Conclusion
Increasing heel height increases medial forefootpressure, impact
force, and perceived discomfort duringIncreasing heel height
signicantly reduced footwearcomfort, however, the uses of the
inserts were effectivein improving footwear comfort. The mean
comfortrating in at shoe was 7.6 and reduced to 2.6 in high
L. Yung-Hui, H. Wei-Hsien / Apwalking. A custom-made insert with
a heel-cup or anversus various heel heights. Gait Posture 4 (4),
280286.
Esenyel, M., Walsh, K., Walden, J.G., Gitter, A., 2003. Kinetics
of
high-heeled gait. J. Am. Podiatr. Med. Assoc. 93 (1), 2732.
Frey, C., Thompson, F., Smith, J., Sanders, M., Horstman, H.,
1993.
American Orthopaedic Foot and Ankle Society womens shoe
survey. Foot Ankle 14 (2), 7881.
Gillespie, K.A., Dickey, J.P., 2003. Determination of the
effectiveness
of materials in attenuating high frequency shock during gait
using
lterbank analysis. Clin. Biomech. 18 (1), 5059.
Hodge, M.C., Bach, T.M., Carter, G.M., 1999. Orthotic
management
of plantar pressure and pain in rheumatoid arthritis. Clin.
Biomech. 14 (8), 567575.
Jorgensen, U., Ekstrand, J., 1988. Signicance of heel pad
connement
for the shock absorption at heel strike. Int. J. Sports Med. 9
(6),(4), 353357.
Boulton, A.J., Franks, C.I., Betts, R.P., Duckworth, T., Ward,
J.D.,
1984. Reduction of abnormal foot pressure in diabetic
neuropathy
using a new polymer insole material. Diabetes Care 7 (1),
4246.
Chen, H., Nigg, B.M., de Koning, J., 1994. Relationship
between
plantar pressure distribution under the foot and insole
comfort.
Clin. Biomech. 9 (6), 335341.
Chen, W.P., Ju, C.W., Tang, F.T., 2003. Effect of total contact
insoles
on the plantar stress redistribution: a nite element analysis.
Clin.
Biomech. 18 (6), s17s24.
Corrigan, J.P., Moore, D.P., Stephens, M.M., 1993. Effect of
heelarch-support mechanism for high-heeled shoes would beeffective
for reductions of heel pressure and impact forceor medial forefoot
pressure, and for an improvement infootwear comfort. In particular,
a TCI, combined with aheel-cup and an arch-support mechanism, could
reduceheel pressure by 25% and medial forefoot pressure by24%,
attenuate the impact force by 33.2%, and offerbetter comfort when
compared to not wearing an insert.It is suggested that these
inserts may contribute torelieve foot pressure, reduced impact
force, and morecomfort at work for women wearing high-heeled
shoes.
Acknowledgements
This study was supported by a grant from theNational Science
Council, ROC (Project No. NSC-92-2213-E-011-041). The authors also
wish to acknowledgeMr. Liu Wen-Long, an orthotic technician from
theDepartment of Physical Medicine and Rehabilitation,Chang Gung
Memorial Hospital, for his assistance withthe fabrication of the
custom-made inserts.
References
Anthony, R., Peter, S.B.L., Karl, L., 2000. Effect of cast and
noncast
foot orthoses on plantar pressure and force during normal
gait.
J. Am. Podiatr. Med. Assoc. 90 (9), 441449.
Barnett, S., Cunningham, J.L., West, S., 2001. A comparison
of
Ergonomics 36 (2005) 355362 361468473.
-
Kadaba, M.P., Ramakrishnan, H.K., Wootten, M.E., Gainey, J.,
Gorton, G., Cochran, G.V., 1989. Repeatability of kinematic,
kinetic, and electromyographic data in normal adult gait.
J. Orthop. Res. 7 (6), 849860.
Kerrigan, D.C., Todd, M.K., Riley, P.O., 1998. Knee
osteoarthritis
and high-heeled shoes. Lancet 351 (9113), 13991401.
Kogler, G.F., Solomonidis, S.E., Paul, J.P., 1996.
Biomechanics
of longitudinal arch support mechanisms in foot orthoses and
their effect on plantar aponeurosis strain. Clin. Biomech. 11
(5),
243252.
Lamb, J., 1991. Multiform moulded insoles. A.P.O. Newsletter 1
(2),
2728.
Lee, G.H., Han, S.J., Lee, S.G., Park, S.B., 2004. The effect
of
metatarsal pad for foot pressure. J. Korean Acad. Rehabil.
Med.
28 (1), 9497.
Levitz, S.J., Dykyj, D., 1990. Improvements in the design of
viscoelastic heel orthoses- a clinical study. J. Am. Podiatr.
Med.
Assoc. 80 (12), 653656.
Light, L.H., Mclellan, G.E., Klenerman, L., 1980. Skeletal
transients
on heel strike in normal walking with different footwear.
J. Biomech. 13 (6), 477480.
Lord, M., Hosein, R., 1994. Pressure redistribution by molded
inserts
in diabetic footwear: a pilot study. J. Rehabil. Res. Dev. 31
(3),
214221.
Mandato, M.G., Nester, E., 1999. The effects of increasing heel
height
on forefoot peak pressure. J. Am. Podiatr. Med. Assoc. 89
(2),
Munermann, A., Nigg, B.M., Stefanyshyn, D.J., Humble, R.N.,
2002.
Development of a reliable method to assess footwear comfort
during running. Gait Posture 16 (1), 3845.
Murray, M.P., Kory, R.C., Sepic, S.B., 1970. Walking patterns
of
normal women. Arch. Phys. Med. Rehabil. 51 (11), 637650.
Opila-Correia, K.A., 1990. Kinematics of high-heeled gait. Arch.
Phys.
Med. Rehabil. 71 (5), 304309.
Schwartz, R.P., Heath, A.L., 1959. Preliminary ndings from a
roentgenographic study of the inuence of heel height and
empirical shank curvature on osteo-articular relationships of
the
normal female foot. J. Bone Jt. Surg. 41A, 324.
Schwartz, R.P., Heath, A.L., Morgan, D.W., Towns, R.C., 1964.
A
quantitative analysis of recorded variables in the walking
pattern of
normal adults. J. Bone Jt. Surg. 46A (2), 321334.
Snow, R.E., Williams, K.R., 1994. High heeled shoes: their
effect on
center of mass position, posture, three-dimensional
kinematics,
rearfoot motion, and ground reaction forces. Arch. Phys.
Med.
Rehabil. 75 (5), 568576.
Snow, R.E., Williams, K.R., Holmes, G.B., 1992. The effects
of
wearing high heeled shoes on pedal pressure in women. Foot
Ankle
13 (2), 8592.
Soames, R.W., Clark, C., 1985. Heel height-induced changes
in
metatarsal loading patterns during gait. In: Winter, D.A.,
Norman,
R.W., Weels, R.P., Hayes, K.C., Patla, A.E. (Eds.),
Biomechanics
IX-A, pp. 446450.
The Gallup Organization, 1986. Womens Attitudes and Usage of
ARTICLE IN PRESSL. Yung-Hui, H. Wei-Hsien / Applied Ergonomics
36 (2005) 355362362McCrory, J.L., Young, M.J., Boulton, A.J.M.,
Cavanagh, P.R., 1997.
Arch index as a predictor of arch height. Foot 7 (2), 7981.
McPoil, T.G., Cornwall, M.W., Yamada, W., 1995. A comparison
of
two in shoe plantar pressure measurement systems. Lower
Extremity 2 (2), 95103.
Morag, E., Cavanagh, P.R., 1999. Structural and functional
predictors
of regional peak pressures under the foot during walking.
J. Biomech. 32 (4), 359370.
Munermann, A., Stefanyshyn, D.J., Nigg, B.M., 2001.
Relationship
between footwear comfort of shoe inserts and anthropometric
and
sensory factors. Med. Sci. Sports Exerc. 33 (11),
19391945.August.
Voloshin, A.S., Loy, D.J., 1994. Biomechanical evaluation
and
management of the shock waves resulting from high-heel gait:
I
temporal domain study. Gait Posture 2 (2), 117122.
Voloshin, A.S., Wosk, J., 1982. An in vivo study of low back
pain and
shock absorption in human locomotor system. J. Biomech. 15
(1),
2127.
Whittle, M.W., 1999. Generation and attenuation of transient
impulsive
forces beneath the foot: a review. Gait Posture 10 (3),
264275.
Wosk, J., Voloshin, A.S., 1981. Wave attenuation in skeletons
of
young healthy persons. J. Biomech. 14 (4), 261267.7580. High
Heel Shoes. The Gallup Organization Inc., Surrey, England,
Effects of shoe inserts and heel height on foot pressure, impact
force, and perceived comfort during
walkingIntroductionMethodsParticipants and
materialsApparatusComfort measurementProceduresData analysis
ResultsDiscussionConclusionAcknowledgementsReferences