Predictors of Barefoot Plantar Pressure during Walking in Patients with Diabetes,Peripheral Neuropathy and a History of Ulceration

ObjectiveElevated dynamic plantar foot pressures significantly increase the risk of foot ulceration in diabetes mellitus. The aim was to determine which factors predict plantar pressures in a population of diabetic patients who are at high-risk of foot ulceration.MethodsPatients with diabetes, peripheral neuropathy and a history of ulceration were eligible for inclusion in this cross sectional study. Demographic data, foot structure and function, and disease-related factors were recorded and used as potential predictor variables in the analyses. Barefoot peak pressures during walking were calculated for the heel, midfoot, forefoot, lesser toes, and hallux regions. Potential predictors were investigated using multivariate linear regression analyses. 167 participants with mean age of 63 years contributed 329 feet to the analyses.ResultsThe regression models were able to predict between 6% (heel) and 41% (midfoot) of the variation in peak plantar pressures. The largest contributing factor in the heel model was glycosylated haemoglobin concentration, in the midfoot Charcot deformity, in the forefoot prominent metatarsal heads, in the lesser toes hammer toe deformity and in the hallux previous ulceration. Variables with local effects (e.g. foot deformity) were stronger predictors of plantar pressure than global features (e.g. body mass, age, gender, or diabetes duration).ConclusionThe presence of local deformity was the largest contributing factor to barefoot dynamic plantar pressure in high-risk diabetic patients and should therefore be adequately managed to reduce plantar pressure and ulcer risk. However, a significant amount of variance is unexplained by the models, which advocates the quantitative measurement of plantar pressures in the clinical risk assessment of the patient.     

Elevated plantar pressures in neuropathic diabetic patients with claw/hammer toe deformity

Elevated plantar foot pressures during gait in diabetic patients with neuropathy have been suggested to result, among other factors, from the distal displacement of sub-metatarsal head (MTH) fat-pad cushions caused by to claw/hammer toe deformity. The purpose of this study was to quantitatively assess these associations. Thirteen neuropathic diabetic subjects with claw/hammer toe deformity, and 13 age- and gender-matched neuropathic diabetic controls without deformity, were examined. Dynamic barefoot plantar pressures were measured with an EMED pressure platform. Peak pressure and force-time integral for each of 11 foot regions were calculated. Degree of toe deformity and the ratio of sub-MTH to sub-phalangeal fat-pad thickness (indicating fat-pad displacement) were measured from sagittal plane magnetic resonance images of the foot. Peak pressures at the MTHs were significantly higher in the patients with toe deformity (mean 626 (SD 260)kPa) when compared with controls (mean 363 (SD 115) kPa, P<0.005). MTH peak pressure was significantly correlated with degree of toe deformity (r=-0.74) and with fat-pad displacement (r=-0.71) (P<0.001). The ratio of force-time integral in the toes and the MTHs (toe-loading index) was significantly lower in the group with deformity. These results show that claw/hammer toe deformity is associated with a distal-to-proximal transfer of load in the forefoot and elevated plantar pressures at the MTHs in neuropathic diabetic patients. Distal displacement of the plantar fat pad is suggested to be the underlying mechanism in this association. These conditions increase the risk for plantar ulceration in these patients.     

Classification of Forefoot Plantar Pressure Distribution in Persons with Diabetes: A Novel Perspective for the Mechanical Management of Diabetic Foot?

Background

The aim of this study was to identify groups of subjects with similar patterns of forefoot loading and verify if specific groups of patients with diabetes could be isolated from non-diabetics.

Methodology/Principal Findings

Ninety-seven patients with diabetes and 33 control participants between 45 and 70 years were prospectively recruited in two Belgian Diabetic Foot Clinics. Barefoot plantar pressure measurements were recorded and subsequently analysed using a semi-automatic total mapping technique. Kmeans cluster analysis was applied on relative regional impulses of six forefoot segments in order to pursue a classification for the control group separately, the diabetic group separately and both groups together. Cluster analysis led to identification of three distinct groups when considering only the control group. For the diabetic group, and the computation considering both groups together, four distinct groups were isolated. Compared to the cluster analysis of the control group an additional forefoot loading pattern was identified. This group comprised diabetic feet only. The relevance of the reported clusters was supported by ANOVA statistics indicating significant differences between different regions of interest and different clusters.

Conclusion/s Significance

There seems to emerge a new era in diabetic foot medicine which embraces the classification of diabetic patients according to their biomechanical profile. Classification of the plantar pressure distribution has the potential to provide a means to determine mechanical interventions for the prevention and/or treatment of the diabetic foot.     

Plantar pressures are higher in cases with diabetic foot ulcers compared to controls despite a longer stance phase duration

Background

Current international guidelines advocate achieving at least a 30 % reduction in maximum plantar pressure to reduce the risk of foot ulcers in people with diabetes. However, whether plantar pressures differ in cases with foot ulcers to controls without ulcers is not clear. The aim of this study was to assess if plantar pressures were higher in patients with active plantar diabetic foot ulcers (cases) compared to patients with diabetes without a foot ulcer history (diabetes controls) and people without diabetes or a foot ulcer history (healthy controls).

Methods

Twenty-one cases with diabetic foot ulcers, 69 diabetes controls and 56 healthy controls were recruited for this case-control study. Plantar pressures at ten sites on both feet and stance phase duration were measured using a pre-established protocol. Primary outcomes were mean peak plantar pressure, pressure-time integral and stance phase duration. Non-parametric analyses were used with Holm’s correction to correct for multiple testing. Binary logistic regression models were used to adjust outcomes for age, sex and body mass index. Median differences with 95 % confidence intervals and Cohen’s d values (standardised mean difference) were reported for all significant outcomes.

Results

The majority of ulcers were located on the plantar surface of the hallux and toes. When adjusted for age, sex and body mass index, the mean peak plantar pressure and pressure-time integral of toes and the mid-foot were significantly higher in cases compared to diabetes and healthy controls (p?<?0.05). The stance phase duration was also significantly higher in cases compared to both control groups (p?<?0.05). The main limitations of the study were the small number of cases studied and the inability to adjust analyses for multiple factors.

Conclusions

This study shows that plantar pressures are higher in cases with active diabetic foot ulcers despite having a longer stance phase duration which would be expected to lower plantar pressure. Whether plantar pressure changes can predict ulcer healing should be the focus of future research. These results highlight the importance of offloading feet during active ulceration in addition to before ulceration.

     

Flat Feet,Happy Feet? Comparison of the Dynamic Plantar Pressure Distribution and Static Medial Foot Geometry between Malawian and Dutch Adults

In contrast to western countries, foot complaints are rare in Africa. This is remarkable, as many African adults walk many hours each day, often barefoot or with worn-out shoes. The reason why Africans can withstand such loading without developing foot complaints might be related to the way the foot is loaded. Therefore, static foot geometry and dynamic plantar pressure distribution of 77 adults from Malawi were compared to 77 adults from the Netherlands. None of the subjects had a history of foot complaints. The plantar pressure pattern as well as the Arch Index (AI) and the trajectory of the center of pressure during the stance phase were calculated and compared between both groups. Standardized pictures were taken from the feet to assess the height of the Medial Longitudinal Arch (MLA). We found that Malawian adults: (1) loaded the midfoot for a longer and the forefoot for a shorter period during roll off, (2) had significantly lower plantar pressures under the heel and a part of the forefoot, and (3) had a larger AI and a lower MLA compared to the Dutch. These findings demonstrate that differences in static foot geometry, foot loading, and roll off technique exist between the two groups. The advantage of the foot loading pattern as shown by the Malawian group is that the plantar pressure is distributed more equally over the foot. This might prevent foot complaints.     

Spatial relationships between shearing stresses and pressure on the plantar skin surface during gait

Based on the hypothesis that diabetic foot lesions have a mechanical etiology, extensive efforts have sought to establish a relationship between ulcer occurrence and plantar pressure distribution. However, these factors are still not fully understood. The purpose of this study was to simultaneously record shear and pressure distributions in the heel and forefoot and to answer whether: (i) peak pressure and peak shear for anterior-posterior (AP) and medio-lateral (ML) occur at different locations, and if (ii) peak pressure is always centrally located between sites of maximum AP and ML shear stresses. A custom built system was used to collect shear and pressure data simultaneously on 11 subjects using the 2-step method. The peak pressure was found to be 362 kPa ± 106 in the heel and 527 kPa ± 123 in the forefoot. In addition, the average peak shear values were higher in the forefoot than in the heel. The greatest shear on the plantar surface of the forefoot occurred in the anterior direction (mean and std. dev.: 37.7 ± 7.6 kPa), whereas for the heel, peak shear the foot was in the posterior direction (21.2 ± 5 kPa). The results of this study suggest that the interactions of the shear forces caused greater "spreading" in the forefoot and greater tissue "dragging" in the heel. The results also showed that peak shear stresses do not occur at the same site or time as peak pressure. This may be an important factor in locating where skin breakdown occurs in patients at high-risk for ulceration.     

Virtually optimized insoles for offloading the diabetic foot: A randomized crossover study

Integration of objective biomechanical measures of foot function into the design process for insoles has been shown to provide enhanced plantar tissue protection for individuals at-risk of plantar ulceration. The use of virtual simulations utilizing numerical modeling techniques offers a potential approach to further optimize these devices. In a patient population at-risk of foot ulceration, we aimed to compare the pressure offloading performance of insoles that were optimized via numerical simulation techniques against shape-based devices. Twenty participants with diabetes and at-risk feet were enrolled in this study. Three pairs of personalized insoles: one based on shape data and subsequently manufactured via direct milling; and two were based on a design derived from shape, pressure, and ultrasound data which underwent a finite element analysis-based virtual optimization procedure. For the latter set of insole designs, one pair was manufactured via direct milling, and a second pair was manufactured through 3D printing. The offloading performance of the insoles was analyzed for forefoot regions identified as having elevated plantar pressures. In 88% of the regions of interest, the use of virtually optimized insoles resulted in lower peak plantar pressures compared to the shape-based devices. Overall, the virtually optimized insoles significantly reduced peak pressures by a mean of 41.3 kPa (p < 0.001, 95% CI [31.1, 51.5]) for milled and 40.5 kPa (p < 0.001, 95% CI [26.4, 54.5]) for printed devices compared to shape-based insoles. The integration of virtual optimization into the insole design process resulted in improved offloading performance compared to standard, shape-based devices.Clinical trial registration: ISRCTN19805071, www.ISRCTN.org.     

Foot internal stress distribution during impact in barefoot running as function of the strike pattern

The aim of the present study is to examine the impact absorption mechanism of the foot for different strike patterns (rearfoot, midfoot and forefoot) using a continuum mechanics approach. A three-dimensional finite element model of the foot was employed to estimate the stress distribution in the foot at the moment of impact during barefoot running. The effects of stress attenuating factors such as the landing angle and the surface stiffness were also analyzed. We characterized rear and forefoot plantar sole behavior in an experimental test, which allowed for refined modeling of plantar pressures for the different strike patterns. Modeling results on the internal stress distributions allow predictions of the susceptibility to injury for particular anatomical structures in the foot.     

Forefoot structural predictors of plantar pressures during walking in people with diabetes and peripheral neuropathy

Various foot structures are thought to influence forefoot plantar pressures during walking. High peak plantar pressures (PPP) during walking in people with diabetes mellitus (DM) and peripheral neuropathy (PN) can cause skin breakdown. The question addressed by this study is "What are the primary forefoot structural factors that predict regional PPP during walking in groups of people with and without DM and PN?" Twenty people with DM and PN (mean age 55+/-9 years, 6 female, 14 male, BMI=33+/-8) and 20 people without DM, matched for gender, age, and BMI were tested. Measures of foot structure were taken from three-dimensional images constructed from spiral X-ray computed tomography. Peak plantar pressure data were recorded during walking. Hierarchical multiple regression analysis was used to predict regional PPP at the great toe and five metatarsal heads from selected structural and walking variables. Metatarsal phalangeal joint angle (hammer toe deformity) was the most important variable predicting pressure, accounting for 19-45% of the PPP variance at five of the six locations in the DM group. Soft tissue thickness, hallux valgus, and forefoot arthropathy were the most important predictors of PPP in the control group. Combinations of structural and walking variables accounted for 47-71% of the variance in the DM group and 52-83% of the variance of PPP during walking in the control group. These structural variables, especially hammer toe deformity, should be considered in attempts to develop strategies to reduce excessive forefoot PPP that may contribute to skin breakdown or other injury.     

Simple finite element models for use in the design of therapeutic footwear

Therapeutic footwear is frequently prescribed in cases of rheumatoid arthritis and diabetes to relieve or redistribute high plantar pressures in the region of the metatarsal heads. Few guidelines exist as to how these interventions should be designed and what effect such interventions actually have on the plantar pressure distribution. Finite element analysis has the potential to assist in the design process by refining a given intervention or identifying an optimal intervention without having to actually build and test each condition. However, complete and detailed foot models based on medical image segmentation have proven time consuming to build and computationally expensive to solve, hindering their utility in practice. Therefore, the goal of the current work was to determine if a simplified patient-specific model could be used to assist in the design of foot orthoses to reduce the plantar pressure in the metatarsal head region. The approach is illustrated by a case study of a diabetic patient experiencing high pressures and pain over the fifth metatarsal head. The simple foot model was initially calibrated by adjusting the individual loads on the metatarsals to approximate measured peak plantar pressure distributions in the barefoot condition to within 3%. This loading was used in various shod conditions to identify an effective orthosis. Model results for metatarsal pads were considerably higher than measured values but predictions for uniform surfaces were generally within 16% of measured values. The approach enabled virtual prototyping of the orthoses, identifying the most favorable approach to redistribute the patient’s plantar pressures.     

Modified pressure distribution patterns in walking following reduction of plantar sensation

The aim of the present study was to investigate the influence of reduced plantar sensation on pressure distribution patterns during gait of 40 healthy subjects (25.3+/-3.3 yr, 70.8+/-10.6 kg and 176.5+/-7.8 cm) with no history of sensory disorders. Plantar sensation in the subjects was reduced by using an ice immersion approach, and reduced sensitivity was tested with Semmes-Weinstein monofilaments. All subjects performed six trials of barefoot walking over a pressure distribution platform under normal as well as iced conditions. Plantar cutaneous sensation was significantly reduced after the cooling procedure (p<0.0001). Pressure distribution analysis showed substantially modified plantar pressure distribution patterns during the roll-over process (ROP) under iced conditions. Analysis of peak pressures revealed significant reductions under the toes and under the heel (p<0.001). The contact time and the relative impulse for the whole foot did not change significantly between the two conditions. For the different areas, a significant load shift from the heel and toes towards the central and lateral forefoot and the lateral midfoot was observed. The results indicate the strong influence of reduced afferent information of the sole of the foot on the ROP in walking.     

Finite element modeling of the first ray of the foot: a tool for the design of interventions

Disorders of the first ray of the foot (defined as the hard and soft tissues of the first metatarsal, the sesamoids, and the phalanges of the great toe) are common, and therapeutic interventions to address these problems range from alterations in footwear to orthopedic surgery. Experimental verification of these procedures is often lacking, and thus, a computational modeling approach could provide a means to explore different interventional strategies. A three-dimensional finite element model of the first ray was developed for this purpose. A hexahedral mesh was constructed from magnetic resonance images of the right foot of a male subject. The soft tissue was assumed to be incompressible and hyperelastic, and the bones were modeled as rigid. Contact with friction between the foot and the floor or footwear was defined, and forces were applied to the base of the first metatarsal. Vertical force was extracted from experimental data, and a posterior force of 0.18 times the vertical force was assumed to represent loading at peak forefoot force in the late-stance phase of walking. The orientation of the model and joint configuration at that instant were obtained by minimizing the difference between model predicted and experimentally measured barefoot plantar pressures. The model were then oriented in a series of postures representative of push-off, and forces and joint moments were decreased to zero simultaneously. The pressure distribution underneath the first ray was obtained for each posture to illustrate changes under three case studies representing hallux limitus, surgical arthrodesis of the first ray, and a footwear intervention. Hallux limitus simulations showed that restriction of metatarsophalangeal joint dorsiflexion was directly related to increase and early occurrence of hallux pressures with severe immobility increasing the hallux pressures by as much as 223%. Modeling arthrodesis illustrated elevated hallux pressures when compared to barefoot and was dependent on fixation angles. One degree change in dorsiflexion and valgus fixation angles introduced approximate changes in peak hallux pressure by 95 and 22 kPa, respectively. Footwear simulations using flat insoles showed that using the given set of materials, reductions of at least 18% and 43% under metatarsal head and hallux, respectively, were possible.     

Effect of heel height on in-shoe localized triaxial stresses

Abnormal and excessive plantar pressure and shear are potential risk factors for high-heeled related foot problems, such as forefoot pain, hallux valgus deformity and calluses. Plantar shear stresses could be of particular importance with an inclined supporting surface of high-heeled shoe. This study aimed to investigate the contact pressures and shear stresses simultaneously between plantar foot and high-heeled shoe over five major weightbearing regions: hallux, heel, first, second and fourth metatarsal heads, using in-shoe triaxial force transducers. During both standing and walking, peak pressure and shear stress shifted from the lateral to the medial forefoot as the heel height increased from 30 to 70mm. Heel height elevation had a greater influence on peak shear than peak pressure. The increase in peak shear was up to 119% during walking, which was about five times that of peak pressure. With increasing heel height, peak posterolateral shear over the hallux at midstance increased, whereas peak pressure at push-off decreased. The increased posterolateral shear could be a contributing factor to hallux deformity. It was found that there were differences in the location and time of occurrence between in-shoe peak pressure and peak shear. In addition, there were significant differences in time of occurrence for the double-peak loading pattern between the resultant horizontal ground reaction force peaks and in-shoe localized peak shears. The abnormal and drastic increase of in-shoe shear stresses might be a critical risk factor for shoe-related foot disorders. In-shoe triaxial stresses should therefore be considered to help in designing proper footwear.     

Biomechanical analysis of the stance phase during barefoot and shod running

This study investigated spatio-temporal variables, ground reaction forces and sagittal and frontal plane kinematics during the stance phase of nine trained subjects running barefoot and shod at three different velocities (3.5, 4.5, 5.5 m s(-1)). Differences between conditions were detected with the general linear method (factorial model). Barefoot running is characterized by a significantly larger external loading rate than the shod condition. The flatter foot placement at touchdown is prepared in free flight, implying an actively induced adaptation strategy. In the barefoot condition, plantar pressure measurements reveal a flatter foot placement to correlate with lower peak heel pressures. Therefore, it is assumed that runners adopt this different touchdown geometry in barefoot running in an attempt to limit the local pressure underneath the heel. A significantly higher leg stiffness during the stance phase was found for the barefoot condition. The sagittal kinematic adaptations between conditions were found in the same way for all subjects and at the three running velocities. However, large individual variations were observed between the runners for the rearfoot kinematics.     

Multi-segment foot kinematics and ground reaction forces during gait of individuals with plantar fasciitis

Background

Clinically, plantar fasciitis (PF) is believed to be a result and/or prolonged by overpronation and excessive loading, but there is little biomechanical data to support this assertion. The purpose of this study was to determine the differences between healthy individuals and those with PF in (1) rearfoot motion, (2) medial forefoot motion, (3) first metatarsal phalangeal joint (FMPJ) motion, and (4) ground reaction forces (GRF).

Methods

We recruited healthy (n=22) and chronic PF individuals (n=22, symptomatic over three months) of similar age, height, weight, and foot shape (p>0.05). Retro-reflective skin markers were fixed according to a multi-segment foot and shank model. Ground reaction forces and three dimensional kinematics of the shank, rearfoot, medial forefoot, and hallux segment were captured as individuals walked at 1.35 ms⁻¹.

Results

Despite similarities in foot anthropometrics, when compared to healthy individuals, individuals with PF exhibited significantly (p<0.05) (1) greater total rearfoot eversion, (2) greater forefoot plantar flexion at initial contact, (3) greater total sagittal plane forefoot motion, (4) greater maximum FMPJ dorsiflexion, and (5) decreased vertical GRF during propulsion.

Conclusion

These data suggest that compared to healthy individuals, individuals with PF exhibit significant differences in foot kinematics and kinetics. Consistent with the theoretical injury mechanisms of PF, we found these individuals to have greater total rearfoot eversion and peak FMPJ dorsiflexion, which may put undue loads on the plantar fascia. Meanwhile, increased medial forefoot plantar flexion at initial contact and decreased propulsive GRF are suggestive of compensatory responses, perhaps to manage pain.     

In-shoe plantar tri-axial stress profiles during maximum-effort cutting maneuvers

Soft tissue injuries, such as anterior cruciate ligament rupture, ankle sprain and foot skin problems, frequently occur during cutting maneuvers. These injuries are often regarded as associated with abnormal joint torque and interfacial friction caused by excessive external and in-shoe shear forces. This study simultaneously investigated the dynamic in-shoe localized plantar pressure and shear stress during lateral shuffling and 45° sidestep cutting maneuvers. Tri-axial force transducers were affixed at the first and second metatarsal heads, lateral forefoot, and heel regions in the midsole of a basketball shoe. Seventeen basketball players executed both cutting maneuvers with maximum efforts. Lateral shuffling cutting had a larger mediolateral braking force than 45° sidestep cutting. This large braking force was concentrated at the first metatarsal head, as indicated by its maximum medial shear stress (312.2±157.0 kPa). During propulsion phase, peak shear stress occurred at the second metatarsal head (271.3±124.3 kPa). Compared with lateral shuffling cutting, 45° sidestep cutting produced larger peak propulsion shear stress (463.0±272.6 kPa) but smaller peak braking shear stress (184.8±181.7 kPa), of which both were found at the first metatarsal head. During both cutting maneuvers, maximum medial and posterior shear stress occurred at the first metatarsal head, whereas maximum pressure occurred at the second metatarsal head. The first and second metatarsal heads sustained relatively high pressure and shear stress and were expected to be susceptible to plantar tissue discomfort or injury. Due to different stress distribution, distinct pressure and shear cushioning mechanisms in basketball footwear might be considered over different foot regions.     

Effect of peak pressure and pressure gradient on subsurface shear stresses in the neuropathic foot

The pressure distribution on the plantar surface of the foot may provide insights into the stresses within the subsurface tissues of patients with diabetes mellitus and peripheral neuropathy (PN) who are at risk for skin breakdown. The purposes of this study were to (1) estimate the stress distribution in the subsurface soft tissue from a measured surface pressure distribution and determine any differences between values in the forefoot and rearfoot, and (2) determine the relationship between maximum shear stress (MSS) (magnitude and depth) and characteristics of the pressure distribution. The measured in-shoe pressure distributions during walking characterized by the peak plantar pressure and maximum pressure gradient on the plantar surface of the feet for 20 subjects with diabetes, PN and history of a mid foot or forefoot plantar ulcer were analyzed. The effects of peak pressure and maximum pressure gradient at the peak pressure location on the stress components in the subsurface soft tissue were studied using a potential function method to estimate the subsurface tissue stress. The calculated MSSs are larger in magnitude and located closer to the surface in the forefoot, where most skin breakdown occurs, compared to the rearfoot. In addition, the MSS (magnitude and depth) is highly correlated with the pressure gradient (r=-0.77 & 0.61) and the peak pressure (r=-0.61 & 0.91). The peak pressure and the maximum pressure gradient obtained from the surface pressure distribution appear to be important variables to identify where MSSs are located in the subsurface tissues on the plantar foot that may lead to skin break down.     

Tendon Achilles lengthening for the treatment of neuropathic ulcers causes a temporary reduction in forefoot pressure associated with changes in plantar flexor power rather than ankle motion during gait

The purposes of this study were to determine the effects of tendon Achilles lengthening (TAL) on ambulatory plantar pressures and ankle range of motion, moment, and power, and to determine whether changes in forefoot pressure after treatment of a neuropathic ulcer are related to changes in ankle dorsiflexion range of motion (DFROM) or plantar flexor (PF) power during gait. Pressure and gait tests were performed before treatment, and at 3 weeks and 8 months after treatment in two randomly assigned groups of subjects with diabetes, equinus deformity, and a neuropathic forefoot ulcer treated with TAL and total contact casting (TAL group, n=14), or total contact casting alone (TCC group, n=14). The TAL group had an initial decrease in forefoot peak pressure (PP) (27%), forefoot pressure-time integral (PTI) (42%), PF moment (53%), and PF power (65%), along with an initial increase in rear foot PP (34%), rear foot PTI (48%), and DFROM (74%). Post-surgical changes in rear foot pressure and DFROM were maintained up to 8 months after treatment with TAL, whereas forefoot pressure and PF moment and power increased significantly. Changes in forefoot pressure after treatment in either group were correlated with changes in PF power (r=0.45-0.60), but not with changes in DFROM during gait (r=-0.02-0.08). Results suggest TAL causes a temporary reduction in forefoot pressure primarily by reducing PF power during gait. The initial decrease in forefoot pressure, followed by progressive reloading of forefoot tissues as PF muscles regain strength after TAL, may help reduce the risk of ulcer recurrence in patients with diabetes.     

New insights into the plantar pressure correlates of walking speed using pedobarographic statistical parametric mapping (pSPM)

This study investigates the relation between walking speed and the distribution of peak plantar pressure and compares a traditional ten-region subsampling (10RS) technique with a new technique: pedobarographic statistical parametric mapping (pSPM). Adapted from cerebral fMRI methodology, pSPM is a digital image processing technique that registers foot pressure images such that homologous structures optimally overlap, thereby enabling statistical tests to be conducted at the pixel level. Following previous experimental protocols, we collected pedobarographic records from 10 subjects walking at three different speeds: slow, normal, and fast. Walking speed was recorded and correlated with the peak pressures extracted from the 10 regions, and subsequently with the peak pixel data extracted after pSPM preprocessing. Both methods revealed significant positive correlation between peak plantar pressure and walking speed over the rearfoot and distal forefoot after Bonferroni correction for multiple comparisons. The 10RS analysis found positive correlation in the midfoot and medial proximal forefoot, but the pixel data exhibited significant negative correlation throughout these regions (p<5x10(-5)). Comparing the statistical maps from the two approaches shows that subsampling may conflate pressure differences evident in pixel-level data, obscuring or even reversing statistical trends. The negative correlation observed in the midfoot implies reduced longitudinal arch collapse with higher walking speeds. We infer that this results from pre- or early-stance phase muscle activity and speculate that preferred walking speed reflects, in part, a balance between the energy required to tighten the longitudinal arch and the apparent propulsive benefits of the stiffened arch.     

The Relationships between Foot Arch Volumes and Dynamic Plantar Pressure during Midstance of Walking in Preschool Children

Objectives

The purpose of this study was to examine the correlation between the foot arch volume measured from static positions and the plantar pressure distribution during walking.

Methods

A total of 27 children, two to six years of age, were included in this study. Measurements of static foot posture were obtained, including navicular height and foot arch volume in sitting and standing positions. Plantar pressure, force and contact areas under ten different regions of the foot were obtained during walking.

Results

The foot arch index was correlated (r = 0.32) with the pressure difference under the midfoot during the foot flat phase. The navicular heights and foot arch volumes in sitting and standing positions were correlated with the mean forces and pressures under the first (r = −0.296∼−0.355) and second metatarsals (r = −0.335∼−0.504) and midfoot (r = −0.331∼−0.496) during the stance phase of walking. The contact areas under the foot were correlated with the foot arch parameters, except for the area under the midfoot.

Conclusions

The foot arch index measured in a static position could be a functional index to predict the dynamic foot functions when walking. The foot arch is a factor which will influence the pressure distribution under the foot. Children with a lower foot arch demonstrated higher mean pressure and force under the medial forefoot and midfoot, and lower contact areas under the foot, except for the midfoot region. Therefore, children with flatfoot may shift their body weight to a more medial foot position when walking, and could be at a higher risk of soft tissue injury in this area.