Manual Therapy xxx (2013) 1e6

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Manual Therapy
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Original article

The influence of high and low heeled shoes on EMG timing characteristics of the
lumbar and hip extensor complex during trunk forward flexion and return task
Anna Mika a, *, Brian C. Clark b, c, qukasz Oleksy a, d
a
Department of Clinical Rehabilitation, University School of Physical Education in Krakow, Al. Jana Pawla II 78, 31-571 Krakow, Poland
b
Ohio Musculoskeletal and Neurological Institute (OMNI), Ohio University, Athens, OH, USA
c
Department of Biomedical Sciences, Ohio University, Athens, OH, USA
d
Zen Machines, Poland

a r t i c l e i n f o a b s t r a c t

Article history: Background: Recent studies suggest that wearing high-heel shoes increases the risk of developing certain
Received 22 August 2012 musculoskeletal pain conditions. In this study we sought to examine whether heel height alters lumbar
Received in revised form and hip extensor muscle timing characteristics during a standardized trunk flexion task.
15 March 2013
Methods: Thirty-one young, healthy women (22e27 years; 168.6
5.1 cm; 57.1
11.8 kg) participated in
Accepted 19 March 2013
this study. Lumbar erector spinae (ES), gluteus maximus (GM), and biceps femoris (BF) electromyo-
graphic (EMG) signals were recorded during a trunk flexion task where subjects were instructed to flex
Keywords:
their trunk in the sagittal plane and then return to a neutral posture. The task was repeated under three
Surface electromyography
Lumbar spine
footwear conditions: while wearing no footwear, while wearing shoes with 4-cm heels, and while
Pelvic crossed syndromes wearing shoes with 10-cm heels. EMG onset and offset times, as well as EMG duration, were calculated
Heel shoes for each muscle and compared across conditions.
Results: We observed a significantly earlier onset of the ES EMG activity (1.36
0.61 vs. 1.56
0.67 s), and
significantly delayed onset of the GM EMG activity (1.72
0.66 vs. 1.28
0.58 s) during the flexion phase
of movement in the 10-cm heeled compared to the no footwear condition. The GM muscle also exhibited
an earlier offset time in the 10-cm heel condition compared to the no footwear condition during the
flexion movement (2.57
0.67 vs. 3.30
0.61 s) as well as during the return from flexion movement
phase (10.87
0.58 vs. 11.69
0.65 s). These alterations in timing characteristic resulted in an overall
decrease in the EMG duration for the GM muscle during the flexion movement.
Conclusion: The results of this study suggest that high-heels alter trunk and hip extensor muscle coor-
dination patterns. These findings, when considered in combination with other recent findings on the
biomechanical effects of wearing high-heels, raise concern about whether wearing high heels results in
abnormal spine loading patterns and increases the risk for developing musculoskeletal injuries.
Ó 2013 Elsevier Ltd. All rights reserved.

1. Introduction
The majority of women have worn high-heel shoes at some time
in their lives, and many women wear them on a regular basis.
Changes in movement patterns (e.g., gait mechanics) associated
with wearing high-heel shoes is clearly evident to the naked eye,
and in recent years scientists have begun to examine the conse-
quences and effects of wearing high-heel shoes (Ebbeling et al.,
1994; Ucanok and Peterson, 2006; Hsue and Su, 2009; Mika et al.,
2009). Painful feet are an extremely common problem among
older women, and many musculoskeletal disorders, such as foot
* Corresponding author. Tel.: þ48 12 6831134; fax: þ48 12 6831300.
E-mail address: anna.mika@awf.krakow.pl (A. Mika).
and knee osteoarthritis, have been associated with wearing shoes
with high-heels (Dawson et al., 2002). Additionally, walking in
high-heeled shoes (as compared to shoes without heels) exerts
other negative effect on the musculoskeletal system, including
increased risks for sprained ankles (Lee et al., 2001), decreased
active range of motion (Opila-Correia, 1990; Bird et al., 2003),
increased muscle fascicle strains (Cronin et al., 2012) as well as
alterations in normal gait patterns (Opila-Correia, 1990; De Lateur
et al., 1991; Mika et al., 2012).
As was shown previously, high-heel shoes increase the height of
the center of body mass thereby creating a more unstable posture
(De Lateur et al., 1991), and also directly impact the lordosis of the
lumbar spine increasing compressive and shear forces (De Lateur
et al., 1991). In order to maintain the abnormal posture some
compensatory changes in muscles activation patterns have been

1356-689X/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.math.2013.03.004

Please cite this article in press as: Mika A, et al., The influence of high and low heeled shoes on EMG timing characteristics of the lumbar and hip
extensor complex during trunk forward flexion and return task, Manual Therapy (2013), http://dx.doi.org/10.1016/j.math.2013.03.004
2 A. Mika et al. / Manual Therapy xxx (2013) 1e6

observed (e.g., increase in erector spinae muscle activity) (Bird
et al., 2003; Barton et al., 2009; Mika et al., 2012a). We have
recently shown that ambulating in high-heeled shoes requires
greater lower extremity (Mika et al., 2012), lumbar erector spinae
(Mika et al., 2012a), and cervical paraspinal muscle (Mika et al.,
2011) electromyographic (EMG) activity. Findings of this nature
have led scientists and clinicians to suggest that wearing high-
heeled shoes repeatedly during a normal day may contribute to
the development of low back pain (Barton et al., 2009) and
increased risk of strain injuries (Cronin et al., 2012).
The importance of impaired muscle coordination patterns as a
potential contributor to low back pain (LBP) has been hypothesized
by Page et al. (2010) and confirmed by Nadler et al. (2001).The
muscle imbalance resulted from biomechanical factors like life-
style, stress, fatigue or repeated movement performed in unnatural
overloading position was linked to changes in neuromuscular co-
ordination and posture (Janda, 1978), which may lead to tissues
overload (Barton et al., 2009). The wearing of high-heeled shoes
may be considered a lifestyle factor. Janda has classified muscle
imbalance patterns as “Upper Crossed Syndrome”, “Lower Crossed
Syndrome” and “Layer Syndrome”. Lower crossed syndrome, also
as “pelvic crossed syndrome,” is characterized by alternating sides
of inhibition (e.g., abdominals, gluteal) and facilitation (e.g.,
thoraco-lumbar extensor, rectus femoris, iliopsoas) in the lower
quarter (Janda, 1986; Page et al., 2010). Therefore, we hypothesized
that if wearing heeled shoes induces muscle imbalances in the
lumbo-pelvic-hip complex similar to those observed in pelvic
crossed syndrome that regularly wearing this type of footwear may
lead to repetitive strain injury in the lumbo-pelvic region.
To date, the majority of studies investigating the effects and
consequences of wearing shoes with high-heels have focused on
the neuromechanical changes observed during walking tasks.
Interestingly, Kim et al. (2011) recently reported that high-heeled
shoes alters the muscle activation patterns (i.e., EMG amplitude
and onset latencies) of the lumbar and upper leg musculature
during a sit-to-stand task. They observed that the onset latency for
the erector spinae muscle was prolonged, and the onset latency for
the medial hamstring and the rectus femoris was shortened.
Further, they observed that the erector spinae and rectus femoris
EMG amplitude values were higher during the task when wearing
8-cm high-heeled shoes, and they interpret their collective findings
to suggest that excessive heel height has the potential to induce
muscle imbalance during sit-to-stand tasks. This finding un-
derscores the need to better understand how wearing shoes with
high-heels alters muscle activation patterns during other activities
of daily living and functional tasks.
In this study we examined the effects of two different heel
heights on the lumbar and hip extensor muscle timing character-
istics during a standardized trunk flexion task (i.e., trunk sagittal
flexion and return from flexion to neutral position). We chose to
examine the effects during a standardized forward-bending task, as
it is a frequently performed task of daily living that requires optimal
neuromuscular coordination and postural adjustments.
history of low back pain or orthopedic limitations of the lower limb
in the six months prior to enrollment in the study.
Study participants were informed in detail about the research
protocol and gave their informed consent to participate in the study.
Local Ethical Committee approval was obtained for this study.
2.2. Study design
EMG activity was measured from the dominant side (i.e., the side
with which individuals self-identified as the dominant side for
handwriting) lumbar erector spinae (ES), gluteus maximus (GM)
and biceps femoris (BF) muscles during sagittal trunk forward
flexion and during return from flexion to neutral standing in random
order in each of three conditions: 1) without footwear, 2) wearing
shoes with a 4 cm heel (‘low heels’), and 3) wearing shoes with a
10 cm heel (‘high heels’). The heels of both the low- and high-heeled
shoes were of the stiletto-heeled type with a base of 1 cm2.
2.3. Standardized trunk flexion task
The standardized trunk flexion task (Mika et al., 2009) consisted
of a two-phase task (Fig.1). During phase I individuals stood in a self-
selected natural and comfortable posture during which 5-s of
baseline EMG activity was recorded. During phase II subjects were
instructed to perform a trunk flexion task with the arms by their
side. Here, subjects flexed their trunk (i.e., bent as far forward as
possible) over a 5-s period (phase IIA in Fig. 1), and then remained in
this maximally flexed position for 3-s (phase IIB in Fig. 1). Then,
beginning from the flexed position, subjects were instructed to re-
turn to a neutral upright position over a 5-s period (i.e., extend your
trunk back to the upright natural posture) (phase IIC in Fig. 1).
During Phase II, verbal feedback was provided as an attempt to
control movement velocity. Specifically, we instructed the subjects
that the entire flexion and extension phases of the movement
should be performed at a smooth and consistent speed, with each of
the flexion and extension phases occurring over a 5-sec period,

2. Material and methods

2.1. Subjects

Thirty-one young, healthy women (22e27 years; 168.6
5.1 cm;

57.1
11.8 kg) participated in this study. All study participants
reported wearing high-heeled shoes occasionally, but not more
frequently than once a month. To ensure that all subjects were
Fig. 1. Temporal analysis of the electromyogram: onset, offset, duration. On-f e onset
familiarized with wearing high-heel shoes we asked them to use time during flexion, Off-f e offset time during flexion, D-f e contraction duration
stiletto type shoes 1 h per day during the week before participating during flexion, On-r e onset time during return from flexion, Off-r e offset time during
in the study. Participants were excluded if they had a previous return from flexion, D-r e contraction duration during return from flexion.

Please cite this article in press as: Mika A, et al., The influence of high and low heeled shoes on EMG timing characteristics of the lumbar and hip
extensor complex during trunk forward flexion and return task, Manual Therapy (2013), http://dx.doi.org/10.1016/j.math.2013.03.004
 A. Mika et al. / Manual Therapy xxx (2013) 1e6
respectively. In trials where the movement timing was substantially
slower or faster than the desired movement time (e.g., when one of
the phases differed by more than w0.5e1 s), the trial was not
analyzed and additional trials were collected. It should be noted that
this movement velocity is slower than what occurs for some daily
functional activities; however, for scientific reasons we desired to
control movement velocity to ensure that this did not change be-
tween experimental conditions or across subjects. Thus, we chose a
somewhat slow movement velocity to ensure that all subjects could
complete the tasks across all conditions in the same time frame.
Prior to formally starting the experiment each subject performed at
least 1 trial in each study condition (without shoes, in low-heels, and
in high-heels) to become more fully familiar with the nature of the
task, appropriate movement velocities, and measurements.
2.4. Electromyographic recordings
EMG signals were recorded from the erector spinae at the L3eL4
vertebral level (ES), gluteus maximus (GM) and biceps femoris (BF)
muscles using a TeleMyo G2 system (Noraxon USA, Inc., Scottsdale,
AZ) according to Surface Electromyography for the Non-Invasive
Assessment of Muscles (SENIAM) guidelines (Hermens et al.,
1999). Prior to electrode placement the skin was cleaned and
degreased with alcohol. Surface electrodes (Ag/AgCl) (BIO LEA-
DLOK) with a 2 cm center-to-center distance were attached along
the direction of the muscle fibers on the bellies of the evaluated
muscles (Merletti and Parker, 2004). The exact placement of the
electrodes followed the recommendations of the SENIAM
(Hermens et al., 1999). EMG data were recorded at a sampling rate
of 1500 Hz and processed according to SENIAM guidelines
(Hermens et al., 1999; Merletti and Parker, 2004) using the MyoR-
esearch software application (Noraxon USA, Inc., Scottsdale, AZ).
EMG data was filtered using builtin hardware 1st order high-pass
filter set to 10 Hz
10% cutoff. The raw EMG data were visually
checked in order to ensure that movement artifact was not incor-
rectly identified as a muscle onset. The EMG signals were rectified
Fig. 2. Representative EMG data from a single subject. ES e erector spinae muscle, GM e gluteus maximus muscle.
Please cite this article in press as: Mika A, et al., The influence of high and low heeled shoes on EMG timing characteristics of the lumbar and hip
extensor complex during trunk forward flexion and return task, Manual Therapy (2013), http://dx.doi.org/10.1016/j.math.2013.03.004
3
and then the root mean squared (RMS) value of the EMG signal was
determined over a 200-msec window (Hermens et al., 1999;
Merletti and Parker, 2004). The EMG onset time of each muscle was
defined as the point at which the signal amplitude exceeded the
mean amplitude plus 3 standard deviations (SD) (Hermens et al.,
1999; Dehail et al., 2007). The offset time was defined as the
point at which the signal amplitude declined below this same
threshold level. The onset and offset time of all bursts of EMG ac-
tivity were calculated in relation to the auditory cue for the subject
to begin the flexion task. During the familiarization trials the sub-
ject was instructed to being the movement task when the “flex”
command was heard. We also gave a warning command during the
end of Phase I to help focus the attention of the subject (Fig. 1). In
addition to calculating onset and offset times we also calculated the
EMG durations (i.e., the time interval between EMG onset and
offset for a respective muscle). The values obtained were compared
between the measurement conducted without footwear and that
for footwear with a low and a high heel Fig. 2.
2.5. Statistical analysis
The statistical analysis was conducted using the STATISTICA 10.0
software package. An Analysis of Variance (ANOVA) test with
repeated measurements was employed for the evaluation of the
significance in the differences of the EMG variables across the three
footwear conditions. When a significant main effect was detected a
Tukey’s post-hoc test was performed. Differences were considered
statistically significant if the level of test probability was lower than
the assumed level of significance (p < 0.05).
3. Results
3.1. EMG onset time
The overall EMG onset sequence during the standardized trunk
flexion task is illustrated in Table 1. During flexion an earlier onset
4 A. Mika et al. / Manual Therapy xxx (2013) 1e6

Table 1
Onset time of the erector spinae (ES), gluteus maximus (GM) and biceps femoris (BF) muscles during the flexion and return from flexion phases of standardized trunk flexion
task.

Outcome measure Flexion Return from flexion

Without shoes Low-heels High-heels Without shoes Low-heels High-heels

ES onset time (s) 1.56
0.67 1.59
0.59 1.36
0.61* 9.22
0.63 8.97
0.56 8.98
0.62
GM onset time (s) 1.28
0.58 1.22
0.49 1.72
0.66 * 9.18
0.61 8.98
0.56 9.01
0.62
BF onset time (s) 1.39
0.61 1.44
0.56 1.54
0.49 1.53
0.68 1.41
0.77 1.34
0.87

*p < 0.05 significantly different onset time in without shoes vs. high-heel condition.

of the ES muscles were noted during the high heel condition
(p < 0.05) (Table 1). Additionally, the GM muscle onset time was
longer during the flexion movement during the high heel condition
(p < 0.05) (Table 1). Heel height had no effect on the onset time of
the BF during flexion (p > 0.05) (Table 1). No differences were
observed in EMG onset patterns between study conditions during
the return from flexion movement (p > 0.05) (Table 1).
3.2. EMG offset time
The overall EMG offset sequence during the standardized trunk
flexion task is illustrated in Table 2. The GM muscle exhibited an
earlier offset time in the high-heeled condition during the flexion
movement as well as during the return from flexion movement
(p < 0.05) (Table 2). No differences were observed in EMG offset
patterns for the ES or BF muscles across the various study condi-
tions (i.e., heel height and movement phase) (p > 0.05) (Table 2).
3.3. EMG duration
The overall EMG duration patterns during the standardized
trunk flexion task are illustrated in Table 3. The GM muscle
exhibited a decreased duration during the flexion movement
(p < 0.05) (Table 3). During return from flexion movement the GM
muscle displayed a slightly lower mean EMG duration in the high
heel condition; however, this decrease failed to reach statistical
significance (p > 0.05) (Table 3).
4. Discussion
The most novel finding of this study is that footwear of the
stiletto type (a heel height of w10 cm) alters the activation patterns
of the lumbar and hip extensor muscles. Specifically, we observed
differential changes in the temporal pattern of muscle activation
when the participants performed standardized trunk flexion task
while wearing high-heeled shoes with the most noticeable alter-
ations being in the timing characteristics of the GM muscle. Here, a
delayed onset during forward flexion and an earlier offset during
both the flexion and return phases were noted. These changes in
GM onset and offset times resulted in on an overall shorter duration
of activity for this muscle. Additionally, we also observed an earlier
onset of the ES muscle during forward flexion phase of the task.
These changes in muscle timing characteristics raise the question of
‘Do the alterations in neuromuscular coordination associated with
increased heel height place individuals at a higher risk for injury
and musculoskeletal pain?’ These effects and consequences may
have clinical significance, which we will discuss in further detail
below.
The functional role of the hip extensor muscles, including the
gluteus and hamstring muscles, has been investigated extensively,
and these muscles seem to be actively involved in lower back sta-
bilization as well as in lumbopelvic rhythm (which is classically
defined as the simultaneous combination of lumbar flexion and
pelvic rotation around the transverse axes of the hip joints during
trunk flexion) (Leinonen et al., 2000; Lee and Wong, 2002;
Milosavljevic et al., 2008). Clinically, hip-spine syndrome (which
describes the complex symptom resulting from concurrent
degenerative hip and degenerative disc disease of the lumbar
spine) has been linked to changes in gluteal muscle activation or-
ders and shortened contraction duration (sometimes referred to as
‘muscle inhibition’) and has been suggested to be associated with
LBP (Kankaanpaa et al., 1998; Page et al., 2010; Cambridge et al.,
2012). Muscle imbalances of this nature (e.g., hyperactivity of
some synergists and hypoactivity of others) as a potential predictor
of LBP has also been hypothesized by some authors (Nadler et al.,
2001; Page et al., 2010). Additionally, reduced GM muscle activity
and increased gluteal fatigability was observed in low back pain
patients during forward bending (Janda, 1986). Some authors have
previously postulated that muscle imbalances occur as a result of
biomechanical mechanisms (Janda, 1978), and our findings suggest
that wearing of heeled shoesd a lifestyle or environmental factord
may contribute to changes in neuromuscular coordination and
posture. The question of if, or how, these factors interact to cause
LBP remain to be determined.
It was previously shown that wearing high-heeled shoes alters
ankle kinetic function compared to low-heeled shoes, and the au-
thors speculated that this change may have resulted in changes in
muscle moments which may predispose long-term wearers of
high-heeled shoes to musculoskeletal pain (Esenyel et al., 2003).
According to Kasman et al. (1998) the normal muscle activation
sequence for forward bending is an initial activation of the lumbar
paraspinals, followed by subsequent activation of the gluteus
maximus, then hamstrings, and plantarflexors, with the reverse
sequence observed on return to neutral standing from flexion. The
stoop lift performed while wearing 10-cm high-heeled shoes
resulted in changes in the GM and ES muscles onset activation

Table 2
Offset time of the erector spinae (ES), gluteus maximus (GM) and biceps femoris (BF) muscles during the flexion and return from flexion phases of tandardized trunk flexion
task.

Outcome measure Flexion Return from flexion

Without shoes Low-heels High-heels Without shoes Low-heels High-heels

ES offset time (s) 3.43
0.80 2.98
0.60 2.94
0.74 10.94
0.67 11.16
0.52 11.14
0.49
GM offset time (s) 3.30
0.61 3.25
0.54 2.75
0.67* 11.69
0.65 11.68
0.71 10.87
0.58*
BF offset time (s) 11.24
0.59 11.15
0.69 11.00
0.87 11.24
0.59 11.15
0.69 11.00
0.87

*p < 0.05 significantly different offset time in without shoes vs. high-heel condition.

Please cite this article in press as: Mika A, et al., The influence of high and low heeled shoes on EMG timing characteristics of the lumbar and hip
extensor complex during trunk forward flexion and return task, Manual Therapy (2013), http://dx.doi.org/10.1016/j.math.2013.03.004
 A. Mika et al. / Manual Therapy xxx (2013) 1e6
Table 3
Onset duration time of the erector spinae (ES), gluteus maximus (GM) and biceps femoris (BF) muscles during the flexion and return from flexion phases of standardized trunk
flexion task.
Outcome measure Flexion
Without shoes Low-heels
ES contraction duration (s) 1.87
0.61 1.39
0.55
GM contraction duration (s) 2.02
0.59 2.03
0.55
BF contraction duration (s) 9.50
0.72 9.47
0.66
*p < 0.05 significantly different contraction duration time in without shoes vs. high-heel condition.
sequence, such that the ES onset occurred earlier and the GM onset
was delayed. We hypothesize that the alterations in onset timing
between these two muscles are related. Specifically, we postulate
that the earlier onset of the ES muscle coupled with the delayed
onset of the GM muscle likely results in overall heightened
compensatory activity in the ES muscles. This pattern of muscles
imbalance observed in our study is similar to the Janda Pelvic
Crossed Syndrome (Page et al., 2010).
The alterations in ES muscle onset as we observed is consistent
with the report of Bird et al. (2003) who investigated the effects of
foot wedging on lumbar ES muscle activation patterns in healthy
participants during walking. They reported a significantly earlier
onset of lumbar ES activity with heel lifts, and suggested that this
alteration in ES activation reinforces lumbar stability prior to the
movement. This increased lumbar ES activity has observed also by
Hodges and Moseley (2003), who has reported changes in the
strategy of trunk muscle control in patients with LBP. It seems likely
that the changes in muscle activation patterns may satisfy immediate
demands for spine function (e.g., increased parspinal activity leading
to increased spine stability); however, it is possible that the long-
term side effects of these altered strategies may be negative and
could potentially lead to a sequelae of unfavorable events. We have
previously proposed that alterations in lumbo-pelvic posture due to
heeled shoes may disrupt correct muscle coordination patterns and
ultimately increase the tissue strain on the lower limbs and spine
(Mika et al., 2011, 2012, 2012a). The data from the present study
contributes to the evidence base from our group and others (De
Lateur et al., 1991; Ebbeling et al., 1994; Nadler et al., 2001; Barton
et al., 2009) in recent years that suggests that wearing of heeled
shoes may pose, in the long-term, negative health consequences.
There are several limitations of this study that need to be
addressed. First, the study population consisted of healthy, young
subjects, so these findings may not be able to be extrapolated to a
patient population and future research should be conducted with
groups of patients with low back problems. Additionally, the sub-
jects in this study were not habitual wearers of high-heeled shoes,
and it is difficult to know if these finds are generalizable to in-
dividuals who regularly wear high-heel shoes. Further, the
methods of determining the EMG onset/offset times were based on
the delivery of an auditory cue, which may be less precise than that
of other methods (e.g., timing patterns based on kinematic pat-
terns); however, this approach is widely used in biomechanical
studies. Lastly, and perhaps most importantly, the design of this
study is observational, and, as such, it is difficult to draw conclu-
sions based on this data about the causal relationship between
alterations in muscles activation pattern due to heeled shoes and
musculoskeletal injuries.
5. Conclusion
Recent studies suggest that wearing high-heel shoes increases
the risk of developing certain musculoskeletal pain conditions, and
in this study we quantified the effects of wearing high-heeled shoes
on the EMG timing characteristics of the lumbar and hip extensor
muscles during a functional trunk flexion task. Our most notable
Please cite this article in press as: Mika A, et al., The influence of high and low heeled shoes on EMG timing characteristics of the lumbar and hip
extensor complex during trunk forward flexion and return task, Manual Therapy (2013), http://dx.doi.org/10.1016/j.math.2013.03.004
5
Return from flexion
High-heels Without shoes Low-heels High-heels
1.51
0.51 1.72
0.56 2.19
0.61 2.15
0.61
1.03
0.45 * 2.51
0.49 2.71
0.56 1.86
0.51
9.28
0.59 9.71
0.69 9.41
0.53 9.66
0.57
observations relate to the timing characteristics of the ES and GM
muscles being altered during the 10-cm heeled condition.
Here, we observed a significantly earlier onset of the ES EMG
activity and a significantly delayed onset of the GM EMG activity
during the flexion phase of movement. The GM muscle also
exhibited an earlier offset time when subjects wore 10-cm heels
during the flexion movement as well as during the return from
flexion movement phase. These findings suggest wearing high-
heels alter trunk and hip extensor muscle coordination patterns.
These findings, when considered in combination with other recent
findings on the biomechanical effects of wearing high-heels, raise
concern about whether wearing high heels results in abnormal
spine loading patterns and increases the risk for developing
musculoskeletal injuries.
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Please cite this article in press as: Mika A, et al., The influence of high and low heeled shoes on EMG timing characteristics of the lumbar and hip
extensor complex during trunk forward flexion and return task, Manual Therapy (2013), http://dx.doi.org/10.1016/j.math.2013.03.004