RESEARCH PAPER

e-ISSN 2329-0072
© Med Sci Tech, 2014; 55: 71-76

Received: 2014.08.29
Accepted: 2014.11.03 Relation between Wearing High-Heeled Shoes
Published: 2014.11.28
and Gastrocnemius and Erector Spine Muscle
Action and Lumbar Lordosis
Authors’ Contribution: ABCD 1 Cezar Augusto Souza Casarin 1 Department of Physical Education, Nove de Julho University (UNINOVE),
Study Design  A ACD 2 Danilo Sales Bocalini São Paulo, Brazil
Data Collection  B 2 Post-Graduation Program in Human Movement Science, Methodist University of
Analysis  C
Statistical ABC 3 Paulo Henrique Marchetti Piracicaba (UNIMEP), Piracicaba, Brazil

Data Interpretation  D AEFG 1 Erinaldo Luiz de Andrade 3 Post-Graduation Program in Physical Education, São Judas Tadeu University
Manuscript Preparation  E CEF 1 Gerson Santos Leite (USJT), São Paulo, Brazil
Literature Search  F 4 Post-Graduation Program in Biophotonic, Nove de Julho University (UNINOVE),
Collection  G
Funds CFG 4 Andrey Jorge Serra São Paulo, Brazil
BEF 1,3 Frank Shiguemitsu Suzuki 5 Department of Morphology, State University of Campinas (UNICAMP), Piracicaba,
ADEFG 5 Paulo Henrique Ferreira Caria Brazil

Corresponding Author: Cezar Augusto Souza Casarin, e-mail: cezarcasarin.x@gmail.com

Source of support: This research was financially supported by CAPES

Background: The extended use of high-heeled shoes is considered a possible cause of low back pain and lumbar hyperlor-
dosis. The aim of this study was to investigate the relationship among lumbar and leg muscles activity, lum-
bar lordosis, and wearing high-heeled shoes.
Material/Methods: Twenty-four adult women (mean age=24) barefoot and wearing heels of 1, 5, and 10 cm height were evaluat-
ed during standing. The gastrocnemius and erector spine muscles were measured by surface electromyogra-
phy and the angle of lumbar curvature by photogrammetry.
Results: There was a correlation between decreased lumbar lordosis and the height of the high-heeled shoes (P£0.05),
the 10-cm high-heeled shoes were the ones that caused higher muscular activity, 5.0 µV, followed by the 5-cm
high-heel, 3.6 µV; the 1-cm high heel, 2.7 µV; and barefoot, 2.3 µV. The gastrocnemius muscles showed high-
er myoelectric activity (14.79%) than erector spine muscles (13.53%). The myoelectric activity of the evaluat-
ed muscles increased concomitantly with increased heel height.
Conclusions: The decreased lumbar lordosis showed that high-heeled shoes are not responsible for lumbar hyperlordosis;
however it does not prevent development of low back pain.

MeSH Keywords: Back Muscles • Electromyography • Muscle, Skeletal • Shoes • Spinal Curvatures

Full-text PDF: http://medscitechnol.com/abstract/index/idArt/892352

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RESEARCH PAPER
Background
High-heeled shoes have been considered a beauty and ele-
gance indicator since the XII century and currently they are
worn even more frequently because of the increasing num-
ber of women having prominent positions in society and the
influence of the more evident esthetic factor [1–3]. However,
these kinds of shoes may damage the spine and feet if worn
excessively. They can change the alignment of the spine and
feet, may compromise muscle efficiency in walking, cause
postural changes, lead to discomfort and muscle fatigue in
the lower back, legs, and feet [4], generate hallux valgus,
heel spurs, foot pressure, and increase the impact force on
the joints [5–7].
These may be warning factors that will lead to lower back pain,
which is one of the major causes of absence from work, recog-
nized as an occupational problem that has become an impor-
tant aspect of job interviews [2,3,8–10]. Standing or walking
for more than 4 hours is enough to promote increased mus-
cular tension in the lumbar back region and cause discomfort
and pain in the body [11–13].
Recent studies have shown that many doctors and therapists
believe that high-heeled shoes increases lumbar lordosis, which
leads to lumbar pain [2]. Other studies corroborate these re-
sults, reporting that clinical tests show that the use of high
heels may cause lumbar hyperlordosis, as well as other neg-
ative effects in the lumbar spine [14–18].
On the other hand, the literature has reported decreased lum-
bar lordosis when wearing high-heeled shoes [19,20–23]. This
relation between lumbar lordosis and wearing high-heeled
shoes diverge hugely in the literature. To help resolve this con-
fusion, we used a methodology similar that of previous stud-
ies [16,18,20], but with greater efficiency. De Lateur et al. [16]
reported that incidence of lumbar lordosis is increasing, Lee et
al. [18] reported it is both increasing and decreasing, and de
Oliveira Pezzan et al. (2011) [20] reported that it is decreasing.
Another important fact is that the wearing of high-heel shoes
cause postural misalignment and muscular adaptations, which
brings the necessity of analyzing the importance of erector spine
muscles action and gastrocnemius in the process of standing
posture, to prove the relation between wearing high-heeled
shoes and lumbar lordosis. Previous studies evaluated the ef-
fects of wearing high-heeled shoes on these muscles, but these
were performed only in an isolated way without any postur-
al analysis [6,24–26].
It is important to highlight other research that obtained di-
verging results regarding the action of these muscles while
wearing high-heeled shoes. Other authors [22] have shown
72
Casarin C.A.S. et al.:
Relation between wearing high-heeled shoes and gastrocnemius and erector spine…
© Med Sci Tech, 2014; 55: 71-76
that the erector spine muscles active electromyographically
in subjects who wore high-heeled shoes, while other authors
have shown these muscles are electromyographically passive
under the same experimental conditions [27].
Because of the conflicting findings on the relationship among
wearing high-heeled shoes, the activity of postural muscles,
and lumbar lordosis, this study aimed to investigate the rela-
tionship between the electromyographic activity of the erec-
tor spine and gastrocnemius muscles and the angle of lumbar
lordosis in volunteers who wear high-heeled shoes.
Material and Methods
Subjects
Twenty-eight women were invited to participate in this study
as volunteers, under the term of consent, with an average age
of 24 years. All of them answered a questionnaire about med-
ical records and frequency of wearing high-heeled shoes un-
der the supervision of the researcher. Then, they were taken
to the electromyography laboratory of the State University of
Campinas and subjected, according Bocalini et al. (2012) [28],
to evaluation of body mass index (BMI) and body posture in
the standing position, through of the line of gravity and pho-
togrammetry at the anterior, lateral, and posterior views, for
pathology identification and marked postural deviation. This
work was submitted to and approved by the Committee on
the Ethics of Research on Human Beings, State University of
Campinas, under Opinion Nº. 187/2003.
Only volunteers having average body mass index (BMI) of 21.8
kg/m2, wearing shoe sizes between 35 and 37 (US & Canada
6.5~8.5), and with no orthopedic restrictions evaluated by a
questionnaire (arthritis, arthrosis, knee valgus or varus, frac-
tures, lesions of the lower limbs) and excessive postural chang-
es (hyperlordosis, hyperkyphosis, scoliosis) were included in
this research. Four volunteers who presented pronounced pos-
tural deviations, supported by medical report, were excluded.
Since the volunteers wore high heels for different lengths of
time, 2 groups were formed. The UH group was made up of
14 volunteers who wore high-heeled shoes for an average of
8 hours per day and the NUH group was made up of 10 vol-
unteers who wore them from 2 to 3 times a week for an av-
erage time of 3 hours per day.
Procedure
Before the commencement of procedures for angle and electro-
myographic analysis, the laboratory was properly prepared with
all instruments and air-conditioned room temperature of 22ºC
to avoid physiological reactions due to temperature changes.
Casarin C.A.S. et al.:
Relation between wearing high-heeled shoes and gastrocnemius and erector spine…
© Med Sci Tech, 2014; 55: 71-76
Figure 1. T
 he angle of lumbar curvature of the vertebral column
of subjects in the standing. Reflective markers were
attached on the spinous process of vertebrae L1 and
L5 analyzed by software Alcimagem.
Angle of lumbar curvature
Analysis of the angle of lumbar curvature of the vertebral col-
umn (lumbar lordosis) was performed with volunteers stand-
ing, the postural alignment defined by a plumb line from the
acromion of the right scapula to the right anterior upper iliac
spine, marked with adhesive tape. Reflective markers were later
attached, and diameter was aligned with the spinous process
of vertebrae L1 and L5 (Figure 1) [16,18,20]. Images of this re-
gion, in the lateral view, were obtained while standing barefoot
(neutral) and wearing shoes with thin heels 1 cm, 5 cm, and 10
cm high. A digital camera (Mavica Sony MVC-FD71®) on a tri-
pod was positioned 70 cm from the target, without zoom [16].
Later, images were analyzed by Alcimagem 2.1® software
(Instrumental Concept and Movement Analysis Laboratory,
Uberlandia, Minas Gerais, Brazil), determining the angle of
the lumbar lordosis in degrees [29]. Angular analysis was per-
formed at random (Figure 1), with 3 repetitions at an interval
Table 1. Mean ±SD values for lumbar angle expressed in degrees for the results of all the shoes studied.
UH Group (n=14)
Shoes (cm)
Mean ±SD
Barefoot 162.54±4.43
Heel Pad 1 cm 163.09±4.06
Heel of 5 cm 163.97±3.62
Heel of 10 cm 164.76±3.72
ANOVA P£0.05
Means followed by P values in rows not differ significantly according to Tukey’s test between the groups (P³0.05) and in columns
differ significantly according to ANOVA for each group (P£0.05). P (interaction)=0.83. UH Group, wore high heels for an average of
eight hours per day, NUH Group, wore high heels from two to three times a week for an average of three hours per day.
73
RESEARCH PAPER
of 7 days between measurements in all recorded images, ac-
cording to the criterion of intra-examiner reliability. Values in
degrees obtained in this assessment were submitted to ANOVA
and Tukey’s test (a=0.05), using SAS software (SAS Institute
Inc., Cary, NC, USA, 9.1, 2003). The accuracy of the instrument
and measurement process was determined by the calculation
of the intraclass correlation coefficients (ICC), with R=96% and
P<0.001, which corrects for systematic errors [30].
Surface electromyography acquisition (sEMG)
The sEMG data were collected in a PCI-DAS 1200 Myosystem
device (ProseconLtda with Myosystem Software - BR1 version
2.52, sample frequency at 2000 Hz, low-pass filter at 500 Hz
and high pass filter at 20 Hz. The myoelectrical activity was
evaluated with a passive bipolar device (Meditrace™® 100,
Series Foam Surface Electrodes, Kendall-LTP, COVIDIEN, United
States) with preamplifiers with a 20-times gain, positioned at
10 mm distance between capture points [31], on skin previous-
ly cleaned with 70% alcohol [32]. The electrodes were placed
according to SENIAM recommendations [33,34]. The reference
electrode was placed on the sternum.
There were 3 bilateral sEMG data of the longissimus and lum-
bar iliocostal (erector spine) muscles and medial and lateral
sections of the gastrocnemius muscle, all with the volunteers
standing barefoot and wearing shoes with 1-cm, 5-cm, and
10-cm heels. All sEMG signals were normalized by the peak
of the values of RMS (Root Mean Square) [16], and submitted
to the parametric statistical analysis, the Friedman test, and
the Mann-Whitney for group analysis (a=0.05).
Results
According to statistics data (P£0.05), the angular analysis showed
decreased lumbar curvature as heel height increased (Table 1).
NUH Group (n=10)
Tukey
Mean ±SD
163.09±6.07 P³0.05
163.61±6.10 P³0.05
164.24±5.83 P³0.05
164.70±5.80 P³0.05
P£0.05
 Casarin C.A.S. et al.:
RESEARCH PAPER Relation between wearing high-heeled shoes and gastrocnemius and erector spine…
© Med Sci Tech, 2014; 55: 71-76

Figure 2. Mean ±SD of the sEMG values

15.3 showing the degree of activity of
15.0 14.79 each muscle in percentage (%). LI,
left lumbar iliocostal; LLG, left lateral
14.7
gastrocnemius; LL, left longissimus;
14.4 14.18 14.20 LMG, left medial gastrocnemius; RI,
right lumbar iliocostal; RLG, right
Mean values (%)

14.1
13.63 lateral gastrocnemius; RL, right
13.8 13.53 13.43 13.42 13.40 longissimus; RMG, right medial
13.5 gastrocnemius.
13.2
12.9
12.6
12.3
RMG RLG LMG LLG RL RI LL LI
Muscles

6.0 60
5.0 51 49
5.0 50

4.0 3.6 40
Mean values (µV)

Mean values (%)

3.0 2.7 30
2.3
2.0 20

1.0 10

0.0 0
10.0 cm 5.0 cm 1.0 cm Barefoot UH NUH
Shoes Groups

Figure 3. M
 ean ±SD of the sEMG values of RMS in microvolts
(µV) for each type of shoes used. Abbreviations: heel of
10 cm, heel of 5 cm,heel pad of 1 cm, barefoot.
In the UH group, the mean values were 162.54° for barefoot;
163.09° for heel 1-cm heels; 163.97° for 5-cm heels, and 164.76°
for 10-cm heels; resulting in a 2.06° decrease. In the NUH group,
the mean values were 163.09° for barefoot; 163.61° for 1-cm
heels; 164.24° for 5-cm heels; and 164.70 for 10-cm heels; re-
sulting in 1.61° of decrease. However, there was no statistical-
ly significant difference between the groups (P³0.05) (Table 1).
Figure 4. Mean ±SD of the sEMG values of RMS in percentage
(%) of groups studied. Abbreviations: UH, who wore
high heels for an average of eight hours; NUH,
volunteers who wore high heels from two to three
times a week for an average of three hours per day.
working to maintain balance throughout the body compared
to the spine erector muscles that support only the segment of
trunk, neck, and head in normal condition of muscular activi-
ty because they were required only at initial adaptation of the
body on the high-heeled shoes to reach equilibrium.

The muscles of the leg showed higher myoelectric activity than
the lumbar muscles in both groups (P£0.05). Values from the
highest to the lowest order: right medial gastrocnemius (RMG)
14.79%; left medial gastrocnemius (LMG) 14.2%; right lateral
gastrocnemius (RLG) 14.18%; left lateral gastrocnemius (LLG)
13.63%. The erector spinae muscles values were: right lon-
gissimus (RL) 13.53%; right lumbar iliocostal (RI) 13.43%; left
longissimus (LL) 13.42% and left lumbar iliocostal (LI) 13.40%;
from both evaluated groups (Figure 2).
Posterior leg muscles were more active, being contracted by the
static plantar flexion caused by high-heeled shoes and also by
The 10-cm high-heeled shoes were the ones that caused higher
muscular activity: 5.0 µV, followed by the 5 cm high-heel, 3.6
µV; the 1-cm high heel, 2.7 µV; and barefoot, 2.3 µV (Figure 3).
Shoes with 10-cm heels were able to induce the ankle joint
to a stronger level of plantar flexion compared to other shoes
evaluated in this study, requiring more contractile activity of
the gastrocnemius muscles.
Significant differences (P£0.05) were found between the mus-
cular activities of the volunteers of the group UH (51%), which
were higher, than that of the NUH group (49%) (Figure 4).

74
Casarin C.A.S. et al.:
Relation between wearing high-heeled shoes and gastrocnemius and erector spine…
© Med Sci Tech, 2014; 55: 71-76
Discussion
The decreased lordosis results were the same found by some
other authors in similar conditions, despite some methodolog-
ical differences. This is because these kinds of shoes shift the
body forward and, as a non-voluntary reaction for balance
maintenance, the body moves backwards [18–21,24].
The decreased lordosis caused by high-heeled shoes alters its
natural curvature, and the higher the heel, the higher is the de-
crease. Thus, the greatest decrease was observed when volun-
teers wore the 10-cm high-heeled shoes. This generates cor-
poral adaptation affecting muscular and joint structures, and
the body balance, increasing stress in the lumbar region. If
worn for more than 4 hours a day, these shoes may cause lo-
cal pain or even accelerate its occurrence in cases of pre-ex-
isting low back pain [11,35].
The discrepancy between our results and those reported by
Lee et al. [16] is due to use of different means of evaluation.
The present study evaluated the body bending angle, not the
lumbar lordosis. Lee et al. misused the term “lumbar bend-
ing angle” and the methodology description to refer to body
bending angle, which confused their analysis. In addition, they
used pads 0, 4, 5, and 8 cm high and did not use high-heeled
shoes for static posture analysis. Furthermore, they only in-
cluded 5 subjects, which limited the results. Therefore, the re-
sults of Lee et al. are not comparable to results of other stud-
ies evaluating changing-lumber lordosis caused by wearing
of high-heeled shoes.
Some conflicting reviews were found in a study that analyzed
the lumbar hyperlordosis and low back pain resulting from
wearing high-heeled shoes [19]. This result was obtained with
only 1 subject used for analysis, making its scientific applica-
tion difficult. The lack of specific studies and scientific rigor
restricts the reliability and application of the results obtained
in this experiment.
Results like these can be found in the literature and in web-
sites, where clinical observations demonstrate that wearing
high-heeled shoes causes lumbar hyperlordosis and low back
pain. For esthetic reasons, patients, especially women, stand
in a poor position with these shoes and, as a consequence,
present the lumbar hyperlordosis. This may lead to some pain,
injuries, and inflammation of the joints and muscles [36–38].
The myoelectric activity of the lumbar muscles responsible for
the trunk extension was not the same of those from the leg
muscles. Different results were obtained in a similar study,
which found no difference among the evaluated muscles. In
that experiment, wooden clubs up to 4.5 cm were used in-
stead of shoes with high heels [27]. This may have hindered
75
RESEARCH PAPER
the corporal control of the volunteers, and the height of the
clubs was insufficient for a more accurate analysis. Another as-
pect that may have interfered with the results was the place-
ment of electrodes, which did not follow testing criteria set
by SENIAM guidelines [31,33].
The muscular behavior of the gastrocnemius muscle was high-
er than the erector spine muscle because these muscles re-
main isometrically contracted while high-heeled shoes were
worn, keeping the ankle in plantar flexion. These muscle fibers
are shorter when standing in high heels, which can contribute
to increased myoelectric activity due to the force-length rela-
tion [4,13,19,39]. Another factor is that the lumbar muscles be-
came less required after the volunteers reached standing bal-
ance after some time spent wearing high-heeled shoes [22,24].
Considering the aspects discussed above, it was determined
that the focus of studies of high-heeled shoes in the litera-
ture is based on the benefits and harm that this type of shoe
can cause to the anatomical structure of the human body.
Thus, the results of this study contribute to this scope, show-
ing negative factors, such as the fact that muscular activity of
the gastrocnemius muscles was higher in the UH group than
in the NUH group during the use of high-heeled shoes in the
standing posture. The leg muscle pump becomes impaired
with the use of high-heeled shoes for long periods, because
the ankle is in constant plantar flexion and for the pump to
act effectively, there needs to be plantar flexion followed by
dorsiflexion to eject the of blood, otherwise the volume de-
creases and venous return of blood increases in this region,
causing vein insufficiency and hypertension [40]. This ana-
tomical and physiological change can become irreversible and
chronic if not prevented, because this deficiency may lead to
venous disease.
Regarding decreased lordosis, the results of this study are
positive because this physical alteration has shown that high-
heeled shoes are not responsible for generating lumbar hyper-
lordosis. However, this fact does not prevent the occurrence
of back pain, because the vertebral column was subjected to
a new position, which can overload the area, requiring further
adjustment in posture, which can cause muscle strains and
nerve compressions resulting in pain [36,37].
Conclusions
The lack of studies confirming these assumptions indicate
the need for future research to better understand this hy-
pothesis, such as measuring activity of the erector spine and
gastrocnemius and the body movements during high-heeled
gait, and investigating the body movements adopted during
high-heeled gait.

RESEARCH PAPER
Thus, the results of this research deserve mention in the lit-
erature of modern woman in the areas of health promotion
and quality of life, as they are topics frequently discussed
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