Heeled shoes increase muscle activity during gait in healthy females: A systematic review and meta-analysis

Background: Altered muscle activity during gait can change the function of the musculoskeletal system and increase the risk of injury. This systematic review and meta-analysis study aimed to investigate the effect of wearing heeled shoes during gait on muscle activity.

Research question: Does wearing different heeled shoes (low: 1.5 < height ≤ 4 cm, medium: 4 < height ≤ 7 cm, high: < 7 cm) change muscle activity during gait in females?

Methods: Systematic literature searches in six electronic databases (Google Scholar, ScienceDirect, Web of Science, PubMed, Scopus, and Cochrane Library) were conducted up to June 2024. Nineteen studies met the inclusion criteria with a total of 401 participants.

Results: The eligible studies had the risk of bias score between 6.5 and 11 (assessed by two independent investigators). Wearing heeled shoes during gait significantly increased overall muscle activity (P < 0.001, 19 studies). Heeled shoes increased the activity of peroneus longus (P = 0.035; three studies), triceps surae (P < 0.001, nine studies), quadriceps (P = 0.001, seven studies), abdominal muscles (P = 0.010; three studies) and trunk extensors (P < 0.001, eight studies), but no significant effect was seen for tibialis anterior (P = 0.084, eight studies), hamstring (P = 0.368; three studies), and head extensors (P = 0.070, three studies). Heeled shoes with high (P < 0.001, 12 studies), medium (P < 0.001, 10 studies) and low heels (P = 0.032; 10 studies) increased muscle activity, although the effect size was large for high and medium (Hedge's g = 1.439 and 0.785, respectively) but small-to-moderate for low-heeled shoes (Hedges' g = 0.460).

Significance: Heeled shoes increase muscle activity in various parts of the body, although low-heeled shoes had small-to-moderate effect size. These findings provide valuable insights for researchers and clinicians and shoe manufacturers for designing optimal heeled shoes.