Journal of Electromyography and Kinesiology 19 (2009) 1071–1078

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Journal of Electromyography and Kinesiology

journal homepage: www.elsevier.com/locate/jelekin

Kinematics and kinetics of the lower extremities of young and elder women
during stairs ascent while wearing low and high-heeled shoes
Bih-Jen Hsue, Fong-Chin Su *
Institute of Biomedical Engineering, National Cheng Kung University, 1 University Road, Tainan 701, Taiwan

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

Article history: The effect of the heel height on the temporal, kinematic and kinetic parameters was investigated in 16
Received 30 January 2008 young and 11 elderly females. Kinematic and kinetic data were collected when the subjects ascended
Received in revised form 17 August 2008 stairs with their preferred speed in two conditions: wearing low-heeled shoes (LHS), and high-heeled
Accepted 14 September 2008
shoes (HHS). The younger adults showed more adjustments in forces and moments at the knee and
hip in frontal and transverse planes. Besides a few significantly changes in joint forces and moments,
the elder group demonstrated longer cycle duration and double stance phase, larger trunk sideflexion
Keywords:
and hip internal rotation, less hip adduction while wearing HHS. Most differences in joint motions
Stairs
Gait
between two groups were found at the hip and knee either in LHS or HHS condition. Instead, the differ-
Biomechanics ences in moment occurred at the hip joint and only in HHS. The interaction of the heel height and age
Age showed the influences of heel height on trunk rotation, hip abduction/adduction, and knee and hip force
Shoe and moment at the frontal plane depended on age. These phenomena suggest that younger and elderly
women adapt their gait and postural control differently during stair ascent (SA) while wearing HHS.
Crown Copyright Ó 2008 Published by Elsevier Ltd. All rights reserved.

1. Introduction strength and power generation at the lower extremities, particular

Stairs negotiation is a common and important activity of daily
living and challenging task for elder people, since the demand for
greater muscle activities and joint range of motion of lower
extremities increases compared to level walking (Andriacchi
et al., 1980; Livingston et al., 1991; McFadyen and Winter, 1988).
Yet, most of the studies in stairs have been restricted to young
adults, or the individuals with certain joint pathologies at the low-
er extremities; biomechanical information about how the elderly
negotiate stairs is still lacking.
Due to age-related declines in the sensory, vestibular, and mus-
culoskeletal functions, slowing of compensatory behavioral re-
sponses and the subsequent injuries are suggestive for the older
person, especially when there are external factors impairing the
recovery from instability. Numerous studies have compared the
differences in gait kinematics and kinetics between young and el-
der populations during level walking (Judge and Davis, 1996; Kerr-
igan et al., 1998; Winter et al., 1990; Hageman and Blanke, 1986;
Ostrosky et al., 1994). It is documented that elderly people tend
to walk slowly with reduced step length, increased step width,
and decreased range of motion at the hip, knee, and ankle joints
as compared with younger population. The deviations in gait for
the elder people may be directly related to the decreased muscle
* Corresponding author. Tel.: +886 6 276 0665; fax.: +886 6 234 3270.
E-mail address: fcsu@mail.ncku.edu.tw (F.-C. Su).
around the distal joints (Judge and Davis, 1996; Thelen et al., 1996;
DeVita and Hortobagyi, 2000). However, the differences in walking
biomechanics may not exist between young and elder adults when
the walking speeds were matched (Kerrigan et al., 1998; Williams
and Bird, 1992). Just then, a redistribution of joint torques and
powers, e.g. using more hip extensors and less knee extensor and
ankle plantarflexor, would be needed for the elderly (Kerrigan
et al., 1998; DeVita and Hortobagyi, 2000; Riley et al., 2001a).
Based on these observations, it is reasonable to assume that the el-
der adults need to make more adjustments in order to successfully
negotiate stairs. Thus a thorough quantitative investigation of the
gait, kinematics and kinetics in stairs is needed for the elderly
population.
The largest numbers of falls in the elderly occur on stairs, but
only few studies have been conducted to evaluate the specific fac-
tors that contribute to falls on stairs. The finding of Simoneau et al.
(1991) suggested that inappropriate foot-stair spatial relationship
between foot and stair was the main reason resulting in falls. It
may account for the report that foot wear is a predictor for falls
in stairways (Templer et al., 1985). Besides the findings of above
studies initiated the idea of choosing heel height as an intervening
factor out of many footwear characters, this study intended to
investigate biomechanical adaptations of the young and elder wo-
men in SA and while wearing shoes with different heel height ow-
ing to two clinical needs. First, elderly females appear to be at
higher risk of stair injury than males based on the high incidence

1050-6411/$34.00 Crown Copyright Ó 2008 Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jelekin.2008.09.005
1072 B. J. Hsue, F. C. Su / Journal of Electromyography and Kinesiology 19 (2009) 1071–1078
of stair accidents in this population and, therefore, the assessment
and identifying risk factors become increasingly more important
(Pauls 1985; Rantanen et al., 1996). Second, in today’s society,
many women wear shoes with high heel in both professional and
social settings, if the increased loads from wearing HHS cannot
be attenuated by changes in kinematics and kinetics of the body,
it may be absorbed directly by soft tissue and accelerate degener-
ative changes. In other words, the HHS wearers must adopt neces-
sary compensatory mechanisms or ability to maintain appropriate
relationship between body segments and between the body and
the environment. Therefore, there is also a clinical need to identify
the biomechanics caused by HHS.
The specific aims of this study were (1) to investigate and com-
pare temporal gait parameters, and kinematics and kinetics of the
ankle, knee and hip joints in the young and elderly adults during
SA; (2) to determine whether heel height influences temporal gait
parameters, kinematics and kinetics; (3) to determine whether the
age influences gait, kinematics and kinetics; (4) to determine
whether the influence of heel height on gait parameters, kinemat-
ics and kinetics depends on age.
2. Methods
Inclusion criteria for the elderly group were (1) above 65 years
of age, (2) able to ascend and descend stairs without using a hand-
rail, and (3) casual HHS wearers who wear HHS at least one day per
week, more than three hours each time. Women who were inter-
ested in participating in this study were interviewed about the
health and medical history and given a physical activity question-
naire (Voorrips et al., 1991). None of the subjects had any orthope-
dic problem, neurological disease, dizziness or major visual
deficits. Each subject had read and signed an approved letter of in-
formed consent.
Subjects included sixteen healthy young females aged 28.7 ± 5.6
years old, and eleven elder females above 70.4 ± 4.4 years old. The
mean weight and height of the older and young groups was
54.0 ± 9.0 Kg and 153.0 ± 3.0 cm, and 52.4 ± 6.4 Kg and 159.3 ±
6.4 cm, respectively.
A five-step wood staircase with a slope of 32.7, and a step
height, tread depth and width of 18 cm, 28 cm and 90 cm, was
used. The fifth step was created by a 120 cm  90 cm platform.
Two portable force plates (Kistler Inc., Switzerland) were secured
on the second and third tread to collect ground reaction forces.
An eight-camera Eagle Motion Analysis System (Motion Analysis
Corporation, Santa Rosa, CA, USA) was used to capture the three-
dimensional trajectory data of the twenty five markers affixed to
the subject’s bilateral anatomical landmarks.
The participants were asked to wear shorts and tight-fitting vest
with dark color during testing. A modified Helen Hayes marker set
with additional markers at the greater trochanter of the femur,
xiphoid process, and 7th cervical spine was used. The markers
which were supposed to be placed at the calcaneus and metacarpal
between 2nd and 3rd toes were attached at the shoe surface cov-
ering these two landmarks; the markers at the lateral and medial
malleolus were not affected.
The subjects walked at their preferred speeds from a start point
about five steps away from the staircase to the top platform recip-
rocally under two conditions: wearing casual LHS with heel height
less than 2 cm (range 1.3–1.8 cm) and HHS with a block heel high-
er than 5.5 cm (range 5.6–6.5 cm) and having a base area of
6 cm  6 cm. Both types of shoes were not ‘slip on’. As measured
by goniometer, the ankle position in static standing ranged from
neutral position to 5° of plantarflexion, and 20°–23° of plantarflex-
ion while wearing LHS and HHS, respectively. Testing consisted of
at least five trials for each condition, and the average of the five
trials was used for comparisons. The order of wearing HHS or
LHS was randomized. One investigator was standing close to the
staircase for protection.
One stride began with heel contact on the second step and
ended with subsequent heel contact of same foot on the fourth
step. One gait cycle was divided into swing phase and stance phase,
and stance phase was further divided into three substance phases:
early stance, single limb support and late stance phases. The early
and late stance phases were phases of double support. The data
was normalized to a stride period of 100% to determine the per-
centage of stance and swing phases in one gait cycle.
Inverse dynamics using linear and angular Newtonian equa-
tions of motion and methods described by Vaughan et al was used
to calculate the joint angles and joint forces and internal moments
in three dimensions (Vaughan et al., 1992). A mediolateral force
took place along the mediolateral axis of the proximal segment,
proximal/distal force took place along the longitudinal axis of the
distal segment, and an anterior/posterior force took place along a
floating axis that is perpendicular to the mediolateral and longitu-
dinal axes. All force and moment data were normalized by body
weight and presented as 100% of the stance phase.
Descriptive statistics were calculated for the time-distance
parameters and peak values of kinematic and kinetic data. The
interaction effect of age and heel height on each parameter was
tested by two-way ANOVA. The level of 0.05 was used to test for
significance. All data were analyzed using the SPSS statistical anal-
ysis software.
3. Results
3.1. Temporal parameters
The temporal phases for SA in shoe conditions are presented in
Table 1. The gait of the elder group is characterized by a significant
larger proportion of stance and terminal double support phases,
and longer cycle duration than the young group either in LHS or
HHS condition. The walking speed of elder group is significantly
slower. The elder females seem to gain stability by increasing the
stance phase, especially while wearing HHS. As comparing the
temporal parameters between shoe conditions, significant differ-
ences are found in cycle duration and double support phase for
the elderly group, and cycle duration for the young group. No inter-
actions between age and heel height were significant on temporal
parameters.
3.2. Kinematic findings
In both shoe conditions, the major differences in peak joint an-
gle between the young and elderly occur at proximal parts, the hip
and knee joints (Table 2). While wearing LHS, the elderly ascend
Table 1
Stance and swing phases in percentages and the cycle duration in seconds.
Cycle (sec) ST (%)a SW (%)b DS (%)c
LHS Y 1.26 ± 0.12 61.19 ± 1.79 38.81 ± 1.79 12.16 ± 1.22
E 1.59 ± 0.21*** 63.40 ± 2.02** 36.60 ± 2.02** 13.35 ± 1.65*
HHS Y 1.31 ± 0.13§ 61.87 ± 1.80 38.12 ± 1.80 12.48 ± 1.55
E 1.67 ± 0.16*,§ 63.64 ± 1.94* 36.36± 1.94* 14.11 ± 2.15***,§
a
ST: stance phase.
b
SW: swing phase.
c
DS: terminal double support.
*
p < 0.05 as comparing old group with young group in same shoe condition.
**
p < 0.01 as comparing old group with young group in same shoe condition.
***
p < 0.005 as comparing old group with young group in same shoe condition.
§
p < 0.05 as comparing HHS with LHS condition in each group.
 B. J. Hsue, F. C. Su / Journal of Electromyography and Kinesiology 19 (2009) 1071–1078 1073

Table 2
Mean maximum peak angle (degrees) of the hip, knee and ankle.

Shoe Joint Age Sagittal plane Frontal plane Transverse plane

a b c d
Flex Extend Abd Add Int Rote Ext Rotf
LHS Trunk E 4.70 ± 4.49 1.69 ± 3.33 6.15 ± 1.71 5.59 ± 3.52 3.25±3.25 1.16 ± 3.88
Y 5.68 ± 7.83 1.98 ± 7.17 5.47±2.56 5.76 ± 2.19 3.33 ± 4.26 3.49 ± 4.35
Hip E 82.61 ± 2.94*** 26.00 ± 2.81*** 0.41 ± 1.83* 14.65 ± 3.66* 6.33 ± 5.49 6.96 ± 5.05
Y 64.98 ± 7.97 12.80 ± 7.87 1.59 ± 2.76 17.96 ± 4.41 7.12 ± 9.46 7.43 ± 8.46
Knee E 93.66 ± 7.13* 16.36 ± 6.91 0.99 ± 3.06*** 8.12 ± 2.04 11.00 ± 3.06 26.23 ± 3.00***
Y 88.34 ± 5.10 12.31 ± 5.08 5.07 ± 3.17 7.00 ± 2.50 13.56 ± 7.01 34.96 ± 8.52
Ankle E 15.24 ± 6.08 20.6 ± 46.06 4.87 ± 5.75 6.20 ± 3.50*** 2.48 ± 5.96 8.46 ± 7.66
Y 14.60 ± 5.12 21.20 ± 6.82 2.11 ± 8.12 13.37 ± 6.66 2.65 ± 10.61 12.37 ± 14.41
HHS Trunk E 5.73 ± 3.12 2.53 ± 2.73 6.40 ± 2.59 6.03 ± 2.10 4.79 ± 3.36§ 0.48 ± 4.05
Y 6.74 ± 7.64 2.31 ± 7.21 6.00 ± 2.19 6.53 ± 2.60§§ 2.69 ± 4.53 3.80 ± 4.28
Hip E 82.44 ± 5.00*** 26.24 ± 4.05*** 1.81 ± 2.80** 13.31 ± 4.27**,§ 10.61 ± 6.61§ 4.34 ± 4.08§
Y 66.08 ± 8.61§ 12.86 ± 8.81 1.63 ± 3.10 17.91 ± 4.16 9.06 ± 7.43 5.73 ± 5.78
Knee E 92.49 ± 7.35 15.25 ± 6.62 0.91 ± 2.82*,§§ 10.12 ± 2.45***,§ 10.79 ± 7.56 25.03 ± 5.96*
Y 87.89 ± 5.02 13.05 ± 6.42 3.91 ± 3.53§ 7.55 ± 1.63 15.9310.93 34.49 ± 9.27
Ankle E 20.52 ± 6.32§§ 11.69 ± 6.44§§§ 0.72 ± 7.31 6.35 ± 7.07* 9.43 ± 5.07§§ 1.11 ± 5.16§
Y 19.93 ± 6.78§§ 16.12 ± 7.31§ 2.81 ± 9.10§ 13.94 ± 5.96 9.19 ± 7.87§ 0.89 ± 9.77§§
a
Plantarflexion for the ankle.
b
Dorsiflexion for the ankle.
c
Side flexion to the left for the trunk, and varus for the ankle.
d
Side flexion to the right for the trunk; valgus for the ankle.
e
Rotation to right side for the trunk; inversion for the ankle.
f
Rotation to the left side for the trunk; eversion for the ankle.
*
p < 0.05 as comparing old group with young group in same shoe condition.
**
p < 0.01 as comparing old group with young group in same shoe condition.
***
p < 0.005 as comparing old group with young group in same shoe condition.
§
p < 0.05 as comparing HHS with LHS condition in each group.
§§
p < 0.01 as comparing HHS with LHS condition in each group.
§§§
p < 0.005 as comparing HHS with LHS condition in each group.

stairs with larger hip (p < 0.005) and knee flexion and adduction planes; they tend to walk with larger trunk sideflexion (p < 0.05),
(p < 0.05), but less knee extension (p < 0.005) than the young sub- and larger hip internal rotation and less external rotation
jects. While wearing HHS, the changes at the proximal joints (p < 0.05), less hip adduction (p < 0.05), and larger knee adduction
mainly in the elderly group take place in the frontal and transverse (p < 0.01). As compared with the young group, the elder group

Trunk flex(+)/extension(-) Hip flex(+)/extension(-) Knee flex(+)/extension(-) Ankle plantar(+)/dorsiflexion(-)

6 100 20
80 stance swing
80 10 stance swing
5 stance swing
60 stance
Degrees

60 0
4 swing
40 40
3 -10
20 20
-20
2
20 40 60 80 100 20 40 60 80 100 20 40 60 80 100 20 40 60 80 100

Trunk side-flexion (+:right, -:left) Hip abd(+)/adduction(-) Knee abd(+)/add(-) Ankle varus(+)/valgus(-)
5 5
stance swing stance swing stance swing
0
5 stance swing
0
0
-5
Degrees

0 -5
-10 -5
-10
-5 -15
-10 -15
20 40 60 80 100 20 40 60 80 100 20 40 60 80 100 20 40 60 80 100

Trunk rotation (+:right, -:left) Hip int(+)/ext(-) rotation Knee int(-)/ext(+) rotation Ankle inv(+)/eversion(-)
10 -10 10

2 -15 stance
5 5
-20
Degrees

0 0
0
-25
-5
-5 stance -30 stance
-2 stance swing swing swing swing
-35 -10
20 40 60 80 100 20 40 60 80 100 20 40 60 80 100 20 40 60 80 100
% of gait cycle % of gait cycle % of gait cycle % of gait cycle

Fig. 1. Trunk, hip, knee and ankle angles for young and elder groups in three planes are presented. The top, middle and bottom plots show the angular displacement in
sagittal, frontal and transverse planes, respectively. The thick line represents young subjects wear LHS; thin line represents young subjects wear HHS; gray line represents
elder subjects wear LHS; dotted line represents elder subjects wear HHS. The vertical solid, and dotted lines separate the stance and swing phase of the young and elder
groups, respectively.
 1074
Table 3

B. J. Hsue, F. C. Su / Journal of Electromyography and Kinesiology 19 (2009) 1071–1078

Mean maximum peak forces (Newton/Kg) and peak moments (Newton-meter/Kg) of the hip, knee and ankle.

Shoe Joint Age Forces Moments

Sagitta plane Frontal plane Transverse plane Sagittal plane Frontal plane Transverse plane
Ant Post Lat Med Prox Dist Flexa Extendb Abdc Addd Int Rote Ext Rotf
***
LHS Hip E 5.76 ± 2.10 0.52 ± 0.13 1.87 ± 0.62 0.74 ± 1.12 0.88 ± 0.24 11.75 ± 3.81 0.13 ± 0.05 1.24 ± 0.44 0.65 ± 0.33 0.01 ± 0.14 0.20 ± 0.12 0.01 ± 0.04***
Y 6.41 ± 0.90 0.87 ± 0.68 1.72 ± 0.66 1.50 ± 0.55 1.03 ± 0.24 13.57 ± 0.89 0.15 ± 0.14 1.12 ± 0.21 0.77 ± 0.24 0.02 ± 0.07 0.26 ± 0.13 0.06 ± 0.03
Knee E 0.20 ± 0.99 4.06 ± 1.01 0.09 ± 0.20 0.93 ± 0.84*** 0.55 ± 0.13 10.48 ± 3.53* 0.16 ± 0.12 0.75 ± 0.36*** 0.28 ± 0.17 0.04 ± 0.14 0.05 ± 0.04 0.04 ± 0.05
Y 0.10 ± 0.15 4.49 ± 0.82 0.00 ± 0.07 1.96 ± 0.41 0.50 ± 0.18 12.40 ± 0.91 0.25 ± 0.13 1.22 ± 0.24 0.29 ± 0.22 0.16 ± 0.17 0.09 ± 0.06 0.05 ± 0.03
Ankle E 10.63 ± 3.71 0.23 ± 0.15 0.24 ± 0.27* 0.56 ± 0.40 0.25 ± 0.19 1.69 ± 0.87 1.21 ± 0.14 0.11 ± 0.35 0.06 ± 0.02 0.02 ± 0.04* 0.06 ± 0.05 0.11 ± 0.07
Y 12.30 ± 0.93 0.24 ± 0.17 0.97 ± 0.96 0.50 ± 0.38 0.30 ± 0.20 2.26 ± 1.01 1.30 ± 0.20 0.00 ± 0.02 0.06 ± 0.03 0.08 ± 0.06 0.04 ± 0.06 0.16 ± 0.08
HHS Hip E 6.76 ± 0.59 0.55 ± 0.13* 1.93 ± 0.65 1.11 ± 0.75 0.90 ± 0.14 13.11 ± 1.02 0.12 ± 0.06 1.50 ± 0.15*** 0.66 ± 0.24**,§ 0.06 ± 0.07** 0.22 ± 0.10* 0.02 ± 0.02*
Y 6.85 ± 0.83§§ 0.86 ± 0.54 1.84 ± 0.61§ 1.59 ± 0.52 0.96 ± 0.22§ 13.69 ± 1.02§ 0.19 ± 0.13 1.13 ± 0.23 0.99 ± 0.31§§ 0.00 ± 0.06 0.32 ± 0.13§§ 0.05 ± 0.04
Knee E 0.11 ± 0.13 3.87 ± 0.95 0.39 ± 0.30***,§§ 0.81 ± 0.56*** 0.54 ± 0.15 11.93 ± 1.04 0.15 ± 0.10 0.83 ± 0.22*** 0.40 ± 0.15§§ 0.05 ± 0.05 0.06 ± 0.04 0.07 ± 0.03
Y 0.18 ± 0.07 4.30 ± 0.56§ 0.01 ± 0.08 1.93 ± 0.59 0.58 ± 0.14 12.58 ± 1.06 0.23 ± 0.12 1.26 ± 0.21 0.41 ± 0.23§§ 0.05 ± 0.13§§ 0.08±0.06 0.08±0.03§
Ankle E 11.80 ± 1.13 0.22 ± 0.16 0.14 ± 0.24* 0.83 ± 0.62 0.06 ± 0.07§§ 3.34 ± 0.45§§ 1.07 ± 0.19§ 0.00 ± 0.01 0.06 ± 0.03* 0.05 ± 0.03 0.02 ± 0.03 0.16 ± 0.07
Y 12.20 ± 1.04 0.28 ± 0.13 0.49 ± 0.56§ 0.51 ± 0.39 0.14 ± 0.11§ 3.67 ± 0.68§§ 1.16 ± 0.20§ 0.00 ± 0.02 0.09 ± 0.03§§ 0.07 ± 0.05 0.03 ± 0.04 0.17 ± 0.08
a
Plantarflexion for the ankle.
b
Dorsiflexion for the ankle.
c
Varus for the ankle.
d
Valgus for the ankle.
e
Inversion for the ankle.
f
Eversion for the ankle.
*
p < 0.05 as comparing old group with young group in same shoe condition.
**
p < 0.01 as comparing old group with young group in same shoe condition.
***
p < 0.005 as comparing old group with young group in same shoe condition.
§
p < 0.05 as comparing HHS with LHS condition in each group.
§§
p < 0.005 as comparing HHS with LHS condition in each group.
 B. J. Hsue, F. C. Su / Journal of Electromyography and Kinesiology 19 (2009) 1071–1078 1075

demonstrates significantly less hip extension (p < 0.005) and
adduction (p < 0.01), less knee adduction (p < 0.01) and ankle val-
gus (p < 0.01).
The differences in motion profiles are more apparent between
groups than between shoe conditions, except the ankle motions
(Fig. 1). Most of peak angles occur at transiting from stance to
swing phase. The elder group has larger hip flexion of 20° than
the young group. The young group demonstrates more trunk for-
ward flexion in particular as wearing HHS. The trunk motions are
computed in relation to pelvis coordinate instead of room coordi-
nate, which may account for the smaller magnitude of trunk mo-
tions as compared with the findings of others’.
Statistically significant interaction between age and heel height
were only shown on peak magnitude of trunk rotation, hip abduc-
tion/adduction. No further interactions were significant on other
kinematic variables.
3.3. Kinetic findings
Overall, heel height has greater effect on the forces and mo-
ments in young group. In the young group, the maxima of lat-
eral-medial (LM) and distal-proximal (DP) forces of the ankle,
posterior-anterior (PA) force of the knee, and the hip forces in three
directions are different between shoe conditions (Table 3). For the
elder group, the maximum of LM force at the knee in HHS is 4
times the force in LHS (p < 0.005). The peak DP forces at the ankle
also significantly change while wearing HHS (p < 0.005). Significant
differences are noted in the ankle (p < 0.05), knee (p < 0.005) and
hip (p < 0.005) forces in ML direction between groups in both shoe
conditions.
The force profiles are quite similar in shoe conditions and two
groups at the hip and knee, except knee force in LM direction
(Fig. 2). The magnitudes and profiles of the LM knee and ankle
forces are quite different between two groups; the elder group
demonstrates smaller LM forces at these two joints. The magnitude
of DP force at the ankle between shoe conditions is different, which
apparently results from the different heel height that HHS cause
greater force in DP direction (for the foot, it was from the toe to
the heel) at the ankle.
Regarding the internal joint moments, HHS increases the hip
abduction moment (p < 0.05) and knee abduction moment
(p < 0.005), and decreases plantarflexion moment (p < 0.05) for
the elder group. For the younger group, all moments in frontal
plane at the hip, knee and ankle, hip internal rotation moment
and ankle plantarflexion and varus moments are significantly dif-
ferent between shoe conditions (Table 3). In LHS, the young group
shows significantly larger knee extension (p < 0.01), ankle valgus
(p < 0.05), and hip external rotation (p < 0.01) moments than the
elderly group. While wearing HHS, the elderly demonstrates signif-
icantly greater hip extension moment (p < 0.005), but less hip
abduction moment (p < 0.01) than the young group.
Similar curve profiles, but different peak moment values, are
found for three joints in the sagittal and transverse planes between
groups and shoe conditions (Fig. 3), The hip and knee extension
moments reach peaks around 20–25% of the stance phase (weight
acceptance or loading response) when the body is pulled up to the
next step, and remains positive for most of the stance phase. The
ankle plantarflexion moment is positive throughout the stance
phase, and reaches peak at the end of the stance phase. It is notice-
able that the elder group demonstrated greater hip extension mo-
ment either in HHS or LHS throughout the stance phase, and the
young group has higher knee extension moment. Both groups have
hip and knee internal rotation moments, and ankle eversion mo-
ment throughout the stance phase. The young group has greater

Hip forces Knee forces Ankle forces

0
1.5
0.5
1
-0.5
0.5
N/ Kg

0
0 -1
-0.5
-1 -1.5
-0.5

20 40 60 80 100 20 40 60 80 100 20 40 60 80 100

0 4
-2

-2 3 -4
N/ Kg

-6
2
-4
-8
1
-10
-6
0 -12
20 40 60 80 100 20 40 60 80 100 20 40 60 80 100
0
-2 -2
-4
-4 -1
-6
-6
N/ Kg

-8 -2
-8
-10
-10
-12 -3
-12
20 40 60 80 100 20 40 60 80 100 20 40 60 80 100
% of stance phase % of stance phase % of stance phase

Fig. 2. Hip, knee and ankle forces about LM (top profiles), PA (middle profiles) and DP (bottom profiles) axes during SA. DP: distal to proximal; PA: posterior to anterior; LM:
lateral to medial. A positive force is in the direction of the specified axis. The thick line represents young subjects wear LHS; thin line represents young subjects wear HHS;
gray line represents elder subjects wear LHS; dotted line represents elder subjects wear HHS.
1076 B. J. Hsue, F. C. Su / Journal of Electromyography and Kinesiology 19 (2009) 1071–1078

Hip moments Knee moments Ankle moments

0 Flex Flex 1.2
0
1 Plantarflex
0.8
Nm/ Kg
-0.5
-0.5
0.6
-1 0.4
Extension -1 0.2
Extension

20 40 60 80 100 20 40 60 80 100 20 40 60 80 100

0.8 0.3 Abd 0.05 Varus

Abd
0.6 0.2
Nm/ Kg

0
0.4
0.1
0.2
0 -0.05 Valgus
Add
0
20 40 60 80 100 20 40 60 80 100 20 40 60 80 100

0.25 Inversion
Int.rot 0
0.2 Int.rot 0.05
Nm/ Kg

0.15 -0.05
0.1 0
0.05 -0.1
Ext.rot
0 Ext.rot Eversion
-0.05 -0.15
20 40 60 80 100 20 40 60 80 100 20 40 60 80 100
% of stance phase % of stance phase % of stance phase

Fig. 3. Hip, knee and ankle moments about sagittal (top), frontal (middle) and transverse (bottom) planes during SA. The thick line represents young subjects wear LHS; thin
line represents young subjects wear HHS; gray line represents elder subjects wear LHS; dotted line represents elder subjects wear HHS.

magnitude than the elder group in these three moments in the
transverse plane. Peak moments are observed also around 20–
25% of the stance phase. A second peak moment of the knee and
ankle is small and observed at 80% of the stance phase when the
body weight starts to shift to the opposite leg.
In contrast to the findings in the sagittal plane, the joint mo-
ments in the frontal plane has more variation, particularly at the
hip and knee joint. The young group has two peaks in abduction
moment at the hip, one around 25–30% of the stance phase and
the other at 85–90%, while the elder group has only one peak at
around 60–65% of the stance phase and one much lower, unobvi-
ous peak at 85% of the stance phase. HHS increases the abduction
moment at the hip and knee for both groups, ankle valgus moment
for the elder group, and ankle varus moment at the end of the
stance phase for the young group.
Significant interaction between age and heel height were found
on peak magnitude of knee force in medial direction, and hip
abduction/adduction and knee adduction moments.
4. Discussion
The objective of this study is to provide a detailed and thorough
description of temporal, kinematic and kinetic parameters of the
gait during SA for the young adults aged below 40 years and elderly
aged over 65 years, and determine the changes in these parameters
when the balance is challenged by wearing HHS.
4.1. The temporal parameters
The time proportion of the stance or swing phase for the two
groups is close to the findings of previous studies (McFadyen and
Winter, 1988; Zachazewski et al., 1993; Nadeau et al., 2003; Riener
et al., 2002), though the average cycle duration is shorter for the
young group and longer for the elder group in both shoe conditions
in present study. The cycle duration for the elder group is also
longer than James and Parker’s findings (1.33 ± 0.15 s) on elder
population (1989). Since the average body height of the young
group was taller than the elder group (159.3 vs. 153.0 cm), we re-
viewed the previous literature about the effect of height on tempo-
ral parameters and compared with our findings. In the study of
Livingston and colleagues (1991), the taller subjects have longer
stance phase and lower cadence than the shorter ones. So, we sug-
gest that the differences in time proportion and cycle duration are
due to age difference, not body height.
4.2. The effect of age
The literature regarding joint forces and moments in three
dimension during SA are limited, particularly in elder population.
The kinetic findings of several studies are presented along with
ours in Table 4. Peak hip and knee abduction moments show more
variations across all studies. The results of this study agree most
closely with those of Costigan et al. (2002). The variations may
come from the dissimilarities in staircase configuration, gender,
age and body figure of the subjects, marker placement, signal man-
agement, and methods of data reduction.
In level walking, the elderly people demonstrate a decrease of
step length associated with reduced ankle joint power in late-
stance (Kerrigan et al., 1998; Hageman and Blanke, 1986). In fast
walking, the elderly people either are not able to generate ankle
plantarflexion power or have limited hip extension (Judge and Da-
vis 1996; Kerrigan et al., 1998; Riley et al., 2001b). Judge et al sug-
gest that elderly people increase hip flexor power to compensate
for the lower ankle plantarflexor power (Judge and Davis, 1996).
DeVita reveals that the elderly used more hip extensors to com-
pensate for the strength loss at the ankle (DeVita and Hortobagyi,
2000). Riley agrees with Kerrigan’s findings that kinematic factors
(e.g. reduced maximal hip extension) would limit gait speed, and
different walking speed would induce different contributions of
hip and knee moment to propulsion power in the elderly (Kerrigan
 B. J. Hsue, F. C. Su / Journal of Electromyography and Kinesiology 19 (2009) 1071–1078
Table 4
Comparison of peak moments of the young group in this study with other researcher’s findings.
Parameters Researchers
Costigan et al. (2002) Kowalk et al. (1996)a
Hip
Abd/add 0.80/0c NA
Flex/extend 0c/0.80 NA
Int/ext rot 0.31/0c NA
Knee
Abd/add 0.42/0c 0.67/0c
Flex/extend 0c/1.16 0.11c/0.92
Int/ext rot 0.1/0c NA
Ankle
Varus/valgus NA NA
Dorsi/planta NA NA
Inv/eversion NA NA
a
The data was originally reported in (% body weight/leg length); the present study converted the values to Nm/kg.
b
The subjects aged over 55 years.
c
The values were estimated from the profiles.
et al., 1998; Riley et al., 1990). In present study, the elder group re-
main in significantly larger hip flexion (26°–82°) throughout the
gait cycle in both shoe conditions. Besides reducing walking veloc-
ity, it may be one of the strategies for the elderly adults to maintain
balance in SA. However, the strategy is associated with greater
internal hip extension moment meaning requiring more work of
hip extensors than the young group (1.24 vs. 1.12 Nm/Kg in LHS,
1.50 vs. 1.13 Nm/Kg in HHS). On the contrary, no difference in knee
angular displacement between groups is found while the young
group has greater knee extension moment, predominantly at the
first half of the stance phase (0.86 vs. 1.23 Nm/Kg). The results of
this study support the previous findings of DeVita on level walking
that aging cause a redistribution of joint torques at the lower
extremity, and more adjustments need to be made at the proximal
joints in the elders when confronting a more demanding activity.
An interesting but easily neglected feature in the knee flex/
extension angle profile is that in late stance phase, the elder group
exhibits a ‘bump’ before the leg swings through to the next step
(Fig. 1). It illustrates that the leg has been consciously or uncon-
sciously moved back and forth to make accommodations, and
may indicate a state of ‘unsteadiness’ or ‘instability’ that the el-
derly subjects are not certain whether the opposite leg is ready
to bear the body weight. This ‘back and forth’ motion at the knee
joint exerts a force on the force plate, and consequently it produces
a second peak in the knee and hip moment in sagittal plane (bot-
tom row in Fig. 3), which is not observed in the young group.
4.3. The effect of heel height and its interaction with age
It has been reported that when wearing HHS, older women have
worst performance in balance tests, e.g. increased body sway dur-
ing static standing and decreased maximal balance range, as com-
pared with barefoot and wearing LHS (Lord and Bashford, 1996).
Nevertheless, in present study, the influences of HHS on the elder
group are less than its influences on the young group in terms of
the peak magnitude changes in kinetics and kinematics. Unlike le-
vel walking in which elder adults can change step length to com-
pensate for inefficient musculoskeletal and neuromuscular
functions, stair climbing has some invariant features that cannot
be compromised. Therefore, the adjustments made by the elder
group when wearing HHS may be more crucial than those made
by the young group in order to advance to the upper step.
From the view point of biomechanics, HHS places the ankle in
plantarflexion which is an open-pack position allowing more joint
movements in ML and diagonal directions, and consequently, HHS
is less stable than LHS (Snow and Williams, 1994; Wu et al., 2004).
An increase in heel height is also associated with an increase in
1077
Nadeau et al. (2003) Kirkwood et al. (1999)b Riener et al. (2002) Hsue
0.99/0c 0.77/0.07 NA 0.77/0.22
0.28/0.53 0.28/1.00 0c/0.53c 0.15/1.12
NA 0.21/0.10 NA 0.26/0.06
0.78/0c NA NA 0.29/0.16
0.24/0.98 NA 0c/1.10c 0.25/1.22
NA NA NA 0.09/0.05
NA NA NA 0.06/0.08
NA/1.17 NA 0c/1.30c 0.00/1.30
NA NA NA 0.04/0.16
inversion and a decrease in maximum eversion during gait, partic-
ularly at foot strike (Fig. 1). As a result, some of the shock absorbing
function of eversion is lost, and the increased loads need to be
attenuated either by changes in kinematics or by direct absorption
by the soft tissues. To prevent the acceleration of tissue degenera-
tion, the compensation by altered kinematics, e.g. increasing flex-
ion at proximal joints, is preferable (Opila-Correia, 1990a,b). This
can be one explanation why the young group has larger trunk
and hip flexion throughout the whole cycle when wearing HHS. In-
stead, the elder group rotates the trunk and hip to compensate for
the possible functional loss at the foot.
Most studies investigating kinematics in SA focus on motions in
the sagittal plane. It is reported the range of motion of the lower
extremity is highly related to the subject’s height and stair dimen-
sions, and the subjects seem to adjust to different stair dimensions
by varying the flexion/extension at the knee rather than that at the
ankle or hip (Livingston et al., 1991). In present study, the height
of the subject increased when wearing HHS, but the major changes
occurred in transverse and frontal planes instead of sagittal plane.
When wearing HHS, the force distribution under the foot changes,
the vertical projection of center of mass shifts anteriorly, and the
base of support during single limb standing is decreased, therefore,
the locomotor control system using sensory input may change. As
stepping forward to catch balance on stairs is not feasible, larger
movements in transverse and frontal planes as compared with level
walking to compensate for the altered foot mechanism is very likely.
The information about the kinetics of HHS gait is very limited
even in level walking. In present study, the joint forces increase
in DP direction when wearing HHS as expected. As well, the shift
of joint forces at the ankle and the knee in ML axis is prominent
when wearing HHS for both groups. The findings partially agree
with the previous report that the forces encountered by the fore-
foot increase with an increased force concentration at the first
metatarsal head and a reduction in force over the fifth metatarsal
head in HHS wearing (McBride et al., 1991; Schwartz et al., 1964).
The results show the influence of heel height on investigated
parameters does not depend on age, except trunk rotation, knee
force in transverse plane, and hip kinematics and kinetics in frontal
plane. From the results of the peak moments and moment profiles,
more adjustments are made for the young group than the elder
group when wearing HHS. For the young group, the major changes
caused by HHS are the increases of peak abduction moment at the
knee (from 0.29 to 0.41 Nm/Kg) and hip (from 0.77 to 0.99 Nm/Kg)
which occur at the ‘pull-up’ phase and late stance phase, respec-
tively. For elder group, greater hip and knee abduction moments,
and ankle eversion moment are required in HHS, with the former
most significant at late stance and the latter two throughout the
1078 B. J. Hsue, F. C. Su / Journal of Electromyography and Kinesiology 19 (2009) 1071–1078
stance phase. Both findings suggest that more work of abductor
and rotator muscles at the lower extremities are required to suc-
cessfully complete the task of SA when wearing HHS.
5. Conclusion
In the current study it was found the younger and elder women
developed different gait adjustments during stair ascent while
wearing HHS. HHS has more significant influences on temporal
and kinematic parameters of the elder group and kinetic parame-
ters of the young group. These adjustments are of concern, given
the potential problems caused by HHS and possible occurrence of
balance loss and joint degeneration with a fail in making these
adjustments. The baseline kinematic and kinetic data and possible
compensatory strategies of healthy elderly women may also en-
able the therapists and clinicians to make comparisons with aging
patients with pathological locomotion characteristics, and aid
health care professionals in evaluating and training elderly individ-
uals in stair negotiation and increasing their functional mobility for
independent living. However, more subjects with different gender
should be included to improve the generalization of the study.
Conflict of Interest Statement
This study did not receive any funding from commercial firms,
private foundations, or government. There were not any financial
and personal relationships with other people or organization that
could influence this.
Acknowledgement
We are grateful to Professors Jia-Jin Chen and Rong-Ju Cherng
for lending us the force plates.
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Bih-Jen Hsue received her B.S., M.A degree in Physi-
cal Therapy from National Taiwan University, and
New York University, respectively, and Ph.D degree
from the Institute of Biomedical Engineering of
National Cheng-Kung University, Taiwan in 2008.
She is a pediatric physical therapist and adjunct
lecturer at the Physical Therapy Department of Foo-
Yin Technology University. Her research interests are
in the field of biomechanics of human motion and
balance control.
Fong-Chin Su received his Ph.D degree major in solid
mechanics and biomechanics from University of
Rochester, USA in 1989. He is Distinguished Profes-
sor and Associate Dean of Engineering, National
Cheng Kung University (NCKU). He is Deputy Editor-
in-Chief of the Journal of Medical and Biological
Engineering and an editorial board member for
Clinical Biomechanics. His major research interests
are in the field of biomechanics, gait analysis and
rehabilitation engineering, and has published 125
journal papers, 331 conference papers and 69 other
publications and edited a conference proceedings
and a book.