Plantar soft tissue thickness during ground contact in walking.

A technique is introduced for the measurement of plantar soft tissue thickness during barefoot walking. Subjects stepped into an adjustable Plexiglas frame which ensured that the required bony landmarks were appropriately positioned relative to a linear ultrasound probe connected to a conventional 7.5 MHz ultrasound scanner. Clear images of the metatarsal condyles or other foot bones were obtained throughout ground contact. Subsequent analysis of the video taped images using a motion analysis system allowed the tissue displacement to be calculated as a function of time. The tissue underneath the second metatarsal head was shown to undergo an average maximum compression of 45.7% during the late stages of ground contact during first step gait in a group of five normal subjects with a mean unloaded tissue thickness of 15.2 mm. The technique has a number of applications, including use in the validation of deformation predicted by finite element models of the soft tissue of the foot, and the study of alterations in the cushioning properties of the heel by devices which constrain the displacement of the heel pad.     

An MRI-compatible foot-loading device for assessment of internal tissue deformation

It is well known that mechanical forces acting within the soft tissues of the foot can contribute to the formation of neuropathic ulcers in people with diabetes. Presently, only surface measurements of plantar pressure are used clinically to estimate risk status due to mechanical loading. It is currently not known how surface measurements relate to the three-dimensional (3-D) internal stress/strain state of the foot. This article describes the development of a foot-loading device that allows for the direct observation of the internal deformation of foot tissues under known forces. Ground reaction forces and plantar pressure distributions during normal walking were measured in ten healthy young adults. One instant in the gait cycle, when pressure under the metatarsal heads reached a peak, was extracted for simulation in an MR imager. T1-weighted 3-D gradient echo MRI sets were collected as the simulated walking ground reaction force was incrementally applied to the foot by the novel foot-loading device. The sub-metatarsal head soft-tissue thickness decreased rapidly at first and then reached a plateau. Peak plantar pressure measurements collected within the loading device (161+/-75kPa) were lower in magnitude and less focal than pressures measured during walking (492+/-91kPa). This finding implies that although the device successfully applied full peak walking ground reaction forces to the foot, they were not distributed in the same manner as during walking. Although not representative of gait, the data collected from this in vivo mechanical test are suitable for determination of foot tissue material properties or, when combined with finite element modeling, to examine the relationship between surface loading and internal stress.     

The shear mechanical properties of diabetic and non-diabetic plantar soft tissue

Changes in the plantar soft tissue shear properties may contribute to ulceration in diabetic patients, however, little is known about these shear parameters. This study examines the elastic and viscoelastic shear behavior of both diabetic and non-diabetic plantar tissue. Previously compression tested plantar tissue specimens (n=54) at six relevant plantar locations (hallux, first, third, and fifth metatarsal heads, lateral midfoot, and calcaneus) from four cadaveric diabetic feet and five non-diabetic feet were utilized. Per in vivo data (i.e., combined deformation patterns of compression followed by shear), an initial static compressive strain (36-38%) was applied to the tissue followed by target shear strains of 50% and 85% of initial thickness. Triangle waves were used to quantify elastic parameters at both strain levels and a stress relaxation test (0.25 s ramp and 300 s hold) was used to quantify the viscoelastic parameters at the upper strain level. Several differences were found between test groups including a 52-62% increase in peak shear stress, a 63% increase in toe shear modulus, a 47% increase in final shear modulus, and a 67% increase in middle slope magnitude (sharper drop in relaxation) in the diabetic tissue. Beyond a 54% greater peak compressive stress in the third metatarsal compared to the lateral midfoot, there were no differences in shear properties between plantar locations. Notably, this study demonstrates that plantar soft tissue with diabetes is stiffer than healthy tissue, thereby compromising its ability to dissipate shear stresses borne by the foot that may increase ulceration risk.     

A novel gait platform to measure isolated plantar metatarsal forces during walking

A new gait platform described in this report allows an isolated measurement of the vertical and shear forces under an individual metatarsal head during barefoot walking. The apparatus incorporated a customized tactile force sensor and a high-speed camera system, which enabled easy identification of a single anatomical landmark at the forefoot’s plantar surface that is in contact with the sensor throughout stance. After calibration, the measured peak forces under the 2nd MTH showed variability of 3.7%, 9.2%, and 8.9% in vertical, anterior–posterior, and medial–lateral directions, respectively. The device therefore provides information about the magnitude and timing of such local metatarsal forces, and has been shown to be of significant research and clinical interest. Its ability to achieve this with a high degree of accuracy ensures its potential as a valuable research tool.     

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.     

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.     

A comparison of bone strain measurements at anatomically relevant sites using surface gauges versus strain gauged bone staples

Instrumented bone staples were first introduced as an alternative to surface-mounted strain gauges for use in human in vivo bone strain measurements because their fixation to bone is secure and requires not only minimally invasive surgery. Bench-top bone bending models have shown that the output from strain gauged bone staples compares favorably to that of traditional mounted gauges. However their within- and across-subject performance at sites typically instrumented in vivo has never been examined. This study used seven human cadaver lower extremities with an age range of 23-81 years old and a dynamic gait simulator to examine and compare axial strains in the mid tibial diaphysis and on the dorsal surface of the second metatarsal as measured simultaneously with strain gauged bone staples and with traditional surface-mounted gauges. Rosette configurations were used at the tibial site for deriving principal compression and tension, and shear strains. Axial outputs from the two gauge types demonstrated strong linear relationships for the tibia (r(2)=0.78-0.94) and the second metatarsal (r(2)=0.96-0.99), but coefficients (slopes) for the relationship were variable (range 7-20), across subjects and across sites. The apparent low reliability of strain gauged staples may be explained by the fact that both strain gauged staples and surface strain gauges are inexact to some degree, do not measure strains from exactly the same areas and strain gauged staples reflect surface strains as well as deformations within the cortex. There were no relationships for the principal tibia compression, tension or shear strain measurements derived from the two rosette gauge types, reflecting the very different anatomical areas measured by each of the constructs in this study. Strain gauged bone staples may be most useful in comparing relative axial intra-subject differences between activities, but inter-subject variability may require larger sample sizes to detect differences between populations.     

Arteriographic study of the arterial supply of the foot in one hundred cadaver feet

The arterial supply of 100 human cadaver feet (87 cadavers) was investigated by stereoscopic arteriography and was compared phylogenetically to that of the macaque foot. The deep plantar arch was always well developed and complete, whereas the superficial plantar arch was usually slender and incomplete. The first proximal perforating artery arising from the dorsalis pedis artery formed the main component of the deep plantar arch in 82% of the feet. The second proximal perforating artery arising from the dorsal rete contributed to the deep plantar arch in 43% of the feet, and formed most of the arch in one foot. The dorsal rete was classified into four groups of variants based on the arterial source of the second dorsal metatarsal artery. These were the arcuate artery (25%), distal lateral tarsal artery (12%), proximal lateral tarsal artery (6%), and nondorsal rete (57%) variants. In the first intermetatarsal space, the dorsal and plantar metatarsal arteries shared a common trunk in 54% of the feet, but this did not occur in the other intermetatarsal spaces. The second dorsal metatarsal artery arose from the dorsal rete in 43% of the feet, and this artery was quite large, sometimes being the largest of all the dorsal and plantar metatarsal arteries. Variations of the arterial supply found in humans sometimes resembled the typical pattern found in the macaque.     

Quantification of a rat tail vertebra model for trabecular bone adaptation studies

A feedback controlled loading apparatus for the rat tail vertebra was developed to deliver precise mechanical loads to the eighth caudal vertebra (C8) via pins inserted into adjacent vertebrae. Cortical bone strains were recorded using strain gages while subjecting the C8 in four cadaveric rats to mechanical loads ranging from 25 to 100 N at 1 Hz with a sinusoidal waveform. Finite element (FE) models, based on micro computed tomography, were constructed for all four C8 for calculations of cortical and trabecular bone tissue strains. The cortical bone strains predicted by FE models agreed with strain gage measurements, thus validating the FE models. The average measured cortical bone strain during 25-100 N loading was between 298 +/- 105 and 1210 +/- 297 microstrain (muepsilon). The models predicted average trabecular bone tissue strains ranging between 135 +/- 35 and 538 +/- 138 mu epsilon in the proximal region, 77 +/- 23-307 +/- 91 muepsilon in the central region, and 155 +/- 36-621 +/- 143 muepsilon in the distal region for 25-100 N loading range. Although these average strains were compressive, it is also interesting that the trabecular bone tissue strain can range from compressive to tensile strains (-1994 to 380 mu epsilon for a 100 N load). With this novel approach that combines an animal model with computational techniques, it could be possible to establish a quantitative relationship between the microscopic stress/strain environment in trabecular bone tissue, and the biosynthetic response and gene expression of bone cells, thereby study bone adaptation.     

Nonlinear behavior of trabecular bone at small strains

Study of the behavior of trabecular bone at strains below 0.40 percent is of clinical and biomechanical importance. The goal of this work was to characterize, with respect to anatomic site, loading mode, and apparent density, the subtle concave downward stress-strain nonlinearity, that has been observed recently for trabecular bone at these strains. Using protocols designed to minimize end-artifacts, 155 cylindrical cores from human vertebrae, proximal tibiae, proximal femora, and bovine proximal tibiae were mechanically tested to yield at 0.50 percent strain per second in tension or compression. The nonlinearity was quantified by the reduction in tangent modulus at 0.20 percent and 0.40 percent strain as compared to the initial modulus. For the pooled data, the mean +/- SD percentage reduction in tangent modulus at 0.20 percent strain was 9.07+/- 3.24 percent in compression and 13.8 +/- 4.79 percent in tension. At 0.40 percent strain, these values were 23.5 +/- 5.71 and 35.7+/- 7.10 percent, respectively. The magnitude of the nonlineari't depended on both anatomic site (p < 0.001) and loading mode (p < 0.001), and in tension was positively correlated with density. Calculated values of elastic modulus and yield properties depended on the strain range chosen to define modulus via a linear curve fit (p < 0.005). Mean percent differences in 0.20 percent offset yield strains were as large as 10.65 percent for some human sites. These results establish that trabecular bone exhibits nonlinearity at low strains, and that this behavior can confound intersite comparisons of mechanical properties. A nonlinear characterization of the small strain behavior of trabecular bone was introduced to characterize the initial stress-strain behavior more thoroughly.     

Effects of fatigue on sarcoplasmic reticulum and myofibrillar properties of rat single muscle fibers.

Force decline during fatigue in skeletal muscle is attributed mainly to progressive alterations of the intracellular milieu. Metabolite changes and the decline in free myoplasmic calcium influence the activation and contractile processes. This study was aimed at evaluating whether fatigue also causes persistent modifications of key myofibrillar and sarcoplasmic reticulum (SR) proteins that contribute to tension reduction. The presence of such modifications was investigated in chemically skinned fibers, a procedure that replaces the fatigued cytoplasm from the muscle fiber with a normal medium. Myofibrillar Ca(2+) sensitivity was reduced in slow-twitch muscle (for example, the pCa value corresponding to 50% of maximum tension was 6.23 +/- 0.03 vs. 5.99 + 0.05, P < 0.01, in rested and fatigued fibers) and not modified in fast-twitch muscle. Phosphorylation of the regulatory myosin light chain isoform increased in fast-twitch muscle. The rate of SR Ca(2+) uptake was increased in slow-twitch muscle fibers (14.2 +/- 1.0 vs. 19.6 +/- 2. 5 nmol. min(-1). mg fiber protein(-1), P < 0.05) and not altered in fast-twitch fibers. No persistent modifications of SR Ca(2+) release properties were found. These results indicate that persistent modifications of myofibrillar and SR properties contribute to fatigue-induced muscle force decline only in slow fibers. These alterations may be either enhanced or counteracted, in vivo, by the metabolic changes that normally occur during fatigue development.     

Effect of footwear on intramuscular EMG activity of plantar flexor muscles in walking

One of the purposes of footwear is to assist locomotion, but some footwear types seem to restrict natural foot motion, which may affect the contribution of ankle plantar flexor muscles to propulsion. This study examined the effects of different footwear conditions on the activity of ankle plantar flexors during walking. Ten healthy habitually shod individuals walked overground in shoes, barefoot and in flip-flops while fine-wire electromyography (EMG) activity was recorded from flexor hallucis longus (FHL), soleus (SOL), and medial and lateral gastrocnemius (MG and LG) muscles. EMG signals were peak-normalised and analysed in the stance phase using Statistical Parametric Mapping (SPM). We found highly individual EMG patterns. Although walking with shoes required higher muscle activity for propulsion than walking barefoot or with flip-flops in most participants, this did not result in statistically significant differences in EMG amplitude between footwear conditions in any muscle (p > 0.05). Time to peak activity showed the lowest coefficient of variation in shod walking (3.5, 7.0, 8.0 and 3.4 for FHL, SOL, MG and LG, respectively). Future studies should clarify the sources and consequences of individual EMG responses to different footwear.     

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.     

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.     

Physiological strain due to load carrying

In an experimental study of load carrying the effects of mass (0, 5.4, 10.4 kg) and the type of support (on the shoulder or on waist) on parameters of physiological strain were quantified to determine the factor(s) which limit carrying time. Four categories of strain were investigated: metabolic (in terms of oxygen uptake), cardiovascular (in terms of heart rate), muscular (in terms of EMG activity) and skin pressure under the shoulder straps. Four young male subjects were tested on a treadmill using different combinations of load and speed. While standing, oxygen uptake was not influenced by the type or mass of the backpack, and averaged 10% maximal oxygen uptake. The heart rate increased significantly by 9 beats per min while standing wearing a backpack, independent of type of support or mass of backpack. While walking both the heart rate and the oxygen uptake were significantly influenced by the mass carried, but both types of strain remained below the tolerance limits for prolonged wear. Standing supporting a load did not significantly increase the root mean square value of the EMG signal of the trapezius pars descendens muscle. While walking, load carrying significantly increased the root mean square value, and, converted to force, the largest increase amounted to 2.7% of the maximal force for a load of 10.4 kg suspended from the shoulders. This was below levels of force producing fatigue, which was also indicated by an absence of changes in the median power frequency of the EMG signal.(ABSTRACT TRUNCATED AT 250 WORDS)     

Nicorandil improves post-fatigue tension in slow skeletal muscle fibers by modulating glutathione redox state

Fatigue is a phenomenon in which force reduction has been linked to impairment of several biochemical processes. In skeletal muscle, the ATP-sensitive potassium channels (K_ATP) are actively involved in myoprotection against metabolic stress. They are present in sarcolemma and mitochondria (mitoK_ATP channels). K⁺ channel openers like nicorandil has been recognized for their ability to protect skeletal muscle from ischemia-reperfusion injury, however, the effects of nicorandil on fatigue in slow skeletal muscle fibers has not been explored, being the aim of this study. Nicorandil (10 μM), improved the muscle function reversing fatigue as increased post-fatigue tension in the peak and total tension significantly with respect to the fatigued condition. However, this beneficial effect was prevented by the mitoK_ATP channel blocker 5-hydroxydecanoate (5-HD, 500 μM) and by the free radical scavenger N-2-mercaptopropionyl glycine (MPG, 1 mM), but not by the nitric oxide (NO) synthase inhibitor Nω-nitro-L-arginine methyl ester (L-NAME, 100 μM). Nicorandil also decreased lipid peroxidation and maintained both reduced glutathione (GSH) levels and an elevated GSH/GSSG ratio, whereas total glutathione (TGSH) remained unaltered during post-fatigue tension. In addition, NO production, measured through nitrite concentrations was significantly increased with nicorandil during post-fatigue tension; this increase remained unaltered in the presence of nicorandil plus L-NAME, nonetheless, this effect was reversed with nicorandil plus MPG. Hence, these results suggest that nicorandil improves the muscle function reversing fatigue in slow skeletal muscle fibers of chicken through its effects not only as a mitoK_ATP channel opener but also as NO donor and as an antioxidant.     

Observation of fatigue unrelated to gross energy reserve of skeletal muscle during tetanic contraction--an application of 31P-MRS

The mechanism of muscle fatigue was studied by 31P-MRS. During tetanic contraction for 2 minutes(min), the tension measured with a strain gauge and Phosphocreatine(PCr)/Inorganic phosphate(Pi)+ Phosphomonoester(PME) ratio decreased to 31.5 +/- 4.4% of the control value and 0.6 +/- 0.1, respectively. The intracellular pH(pH) also decreased to 6.62 +/- 0.04. Toward the end of the stimulation, the tension decreased to 25.3 +/- 1.9% of the control value. However, during 20min stimulation, the PCr/(Pi+PME) ratio increased to 2.5 +/- 0.5 and the pH to 6.91 +/- 0.04. These results show that muscular fatigue is ascribable not to a decreased level of high energy metabolites required for actomyosin ATPase, but to an increase in the threshold intensity of excitation in excitation-contraction coupling.     

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.     

Parametric study of orthopedic insole of valgus foot on partial foot amputation

Orthopedic insole was important for partial foot amputation (PFA) to achieve foot balance and avoid foot deformity. The inapposite insole orthosis was thought to be one of the risk factors of reamputation for foot valgus patient, but biomechanical effects of internal tissues on valgus foot had not been clearly addressed. In this study, plantar pressure on heel and metatarsal regions of PFA was measured using F-Scan. The three-dimensional finite element (FE) model of partial foot evaluated different medial wedge angles (MWAs) (0.0°–10.0°) of orthopedic insole on valgus foot. The effect of orthopedic insole on the internal bone stress, the medial ligament tension of ankle, plantar fascia tension, and plantar pressure was investigated. Plantar pressure on medial heel region was about 2.5 times higher than that of lateral region based on the F-Scan measurements. FE-predicted results showed that the tension of medial ankle ligaments was the lowest, and the plantar pressure was redistributed around the heel, the first metatarsal, and the lateral longitudinal arch regions when MWA of orthopedic insole ranged from 7.5° to 8.0°. The plantar fascias maintained about 3.5% of the total load bearing on foot. However, the internal stresses from foot bones increased. The simulation in this study would provide the suggestion of guiding optimal design of orthopedic insole and therapeutic planning to pedorthist.