Habitually wearing high heels may improve user walking economy in any footwear.

The habitual use of high-heeled footwear may structurally remodel user leg muscle tendons, thereby altering their functional capabilities. High heels set users' ankles in relatively plantarflexed positions, causing calf muscle tendons to operate at relatively short lengths. Habitually operating muscle tendons at relatively short lengths induces structural remodeling that theoretically affects muscle metabolism. Because structural changes occur within the body, the user's locomotor metabolism may change in any footwear condition (e.g., conventional shoes, barefoot). Here, we studied the influence of habitual high-heel use on users' leg muscle-tendon structure and metabolism during walking in flat-soled footwear. We tested eight participants before and after 14 wk of agreeing to wear high heels as their daily shoes. Overall, participants who wore high heels >1,500 steps per day, experienced a 9% decrease in their net metabolic power during walking in flat-soled footwear (d = 1.66, P ≤ 0.049), whereas participants who took <1,000 daily steps in high heels did not (d = 0.44; P = 0.524). Across participants, for every 1,000 daily steps in high heels, net metabolic power during walking in flat-soled footwear decreased 5.3% (r = -0.73; P = 0.040). Metabolic findings were partially explained (r2 = 0.43; P = 0.478) by trending shorter medial gastrocnemius fascicle lengths (d = 0.500, P = 0.327) and increased Achilles tendon stiffness (d = 2.889, P = 0.088). The high-heel intervention did not alter user walking stride kinematics in flat-soled footwear (d ≤ 0.567, P ≥ 0.387). While our limited dataset is unable to establish the mechanisms underlying the high-heel-induced walking economy improvement, it appears that prescribing specific footwear use can be implemented to alter user muscle-tendon properties and augment their function in any shoes.NEW & NOTEWORTHY Habitually wearing high-heeled footwear structurally remodels leg muscle tendons and improves user walking economy, regardless of worn attire.

Subject-specific material properties of the heel pad: An inverse finite element analysis.

Individuals with diabetes are at a higher risk of developing foot ulcers. To better understand internal soft tissue loading and potential treatment options, subject-specific finite element (FE) foot models have been used. However, existing models typically lack subject-specific soft tissue material properties and only utilize subject-specific anatomy. Therefore, this study determined subject-specific hindfoot soft tissue material properties from one non-diabetic and one diabetic subject using inverse FE analysis. Each subject underwent cyclic MRI experiments to simulate physiological gait and to obtain compressive force and three-dimensional soft tissue imaging data at 16 phases along the loading-unloading cycles. The FE models consisted of rigid bones and nearly-incompressible first-order Ogden hyperelastic skin, fat, and muscle (resulting in six independent material parameters). Then, calcaneus and loading platen kinematics were computed from imaging data and prescribed to the FE model. Two analyses were performed for each subject. First, the skin, fat, and muscle layers were lumped into a single generic soft tissue material and optimized to the platen force. Second, the skin, fat, and muscle material properties were individually determined by simultaneously optimizing for platen force, muscle vertical displacement, and skin mediolateral bulging. Our results indicated that compared to the individual without diabetes, the individual with diabetes had stiffer generic soft tissue behavior at high strain and that the only substantially stiffer multi-material layer was fat tissue. Thus, we suggest that this protocol serves as a guideline for exploring differences in non-diabetic and diabetic soft tissue material properties in a larger population.

The Single Leg Heel Rise Test-A Helpful Tool for Dance Science?: A Systematic Review.

BACKGROUND: Foot and ankle injuries are the most prevalent injuries in dance. The single leg heel-rise (SLHR) test is a simple tool to assess muscular endurance of the plantar flexors of the foot and is an increasingly popular manual muscle test in various areas of dance. Although the SLHR test has shown high reliability and validity in the medical field, no uniform description of this test exists in dance. OBJECTIVE: This systematic review aimed to identify parameters, outcome measures, purposes, and existing normative values of the SLHR test in the dance field. METHODS: Following the PRISMA guidelines, the electronic databases Scopus, PubMed, SPORTDiscus, EMBASE, CINAHL, and Cochrane were searched using a predefined search strategy up to June 2022. Studies were included if they reported screening, testing, or evaluation of either muscular endurance or strength of the calf muscle-tendon unit (MUT) in dancers using the SLHR test. The methodological quality of the studies was evaluated using a modified version of the Downs and Black Quality Index. RESULTS: A total of 180 studies were identified. Twelve studies comprising a total of 427 dancers met the inclusion criteria. Key testing parameters of the SLHR test varied widely or were not reported. The average quality rating of the reviewed studies was 12.9 (range 8 to 17) out of a possible 20 points. DISCUSSION: Although commonly used in test batteries, there are no standardized parameters of the SLHR test used in the dance field. Therefore, no generally applicable normative values could be established. CONCLUSION: Key parameters such as the precise execution of the heel rises should be reported in testing protocols. For the SLHR test to be a useful tool in dance, further research on the influence of dance style, age, and injuries to the calf MTU on this test is needed.

A fluoroscopic imaging-guided computational analyses to inform internal tissue loads within fat pad of the diabetic foot during gait.

To accurately predict internal tissue loads for early diagnostics of diabetic foot ulcerations, a novel data-driven computational analysis was conducted. A dedicated dual fluoroscopic system was combined with a pressure mat to simultaneously characterize foot motions and soft tissue's material properties during gait. Finite element (FE) models of the heel pad of a diabetic patient were constructed with 3D trajectories of the calcaneus applied as boundary conditions to simulate gait events. The tensile and compressive stresses occurring in the plantar tissue were computed. Predictions of the layered tissue FE model with anatomically-accurate heel pad structures (i.e., fat and skin) were compared with those of the traditional lumped tissue (i.e., homogeneous) models. The influence of different material properties (patient-specific versus generic) on internal tissue stresses was also investigated. The results showed the peak tensile stresses in the layered tissue model were predominantly found in the skin and distributed towards the circumferential regions of the heel, while peak compressive stresses in the fat tissue-bone interface were up to 51.4% lower than those seen in the lumped models. Performing FE analyses at four different phases of walking revealed that ignorance of layered tissue structures resulted in an unphysiological increase of peak-to-peak value of stress fluctuation in the fat and skin tissue components. Thus, to produce more clinical-relevant predictions, foot FE models are suggested to include layered tissue structures of the plantar tissue for an improved estimation of internal stresses in the diabetic foot in gait.

Definition and evaluation of a finite element model of the human heel for diabetic foot ulcer prevention under shearing loads.

Diabetic foot ulcers are triggered by mechanical loadings applied to the surface of the plantar skin. Strain is considered to play a crucial role in relation to ulcer etiology and can be assessed by Finite Element (FE) modeling. A difficulty in the generation of these models is the choice of the soft tissue material properties. In the literature, many studies attempt to model the behavior of the heel soft tissues by implementing constitutive laws that can differ significantly in terms of mechanical response. Moreover, current FE models lack of proper evaluation techniques that could estimate their ability to simulate realistic strains. In this article, we propose and evaluate a FE model of the human heel for diabetic foot ulcer prevention. Soft tissue constitutive laws are defined through the fitting of experimental stretch-stress curves published in the literature. The model is then evaluated through Digital Volume Correlation (DVC) based on non-rigid 3D Magnetic Resonance Image Registration. The results from FE analysis and DVC show similar strain locations in the fat pad and strain intensities according to the type of applied loads. For additional comparisons, different sets of constitutive models published in the literature are applied into the proposed FE mesh and simulated with the same boundary conditions. In this case, the results in terms of strains show great diversity in locations and intensities, suggesting that more research should be developed to gain insight into the mechanical properties of these tissues.

Modification of the locomotor pattern when deviating from the characteristic heel-to-toe rolling pattern during walking.

PURPOSE: Humans are amongst few animals that step first on the heel, and then roll on the ball of the foot and toes. While this heel-to-toe rolling pattern has been shown to render an energetic advantage during walking, the effect of different foot contact strategies, on the neuromuscular control of adult walking gaits has received less attention. We hypothesised that deviating from heel-to-toe rolling pattern affects the energy transduction and weight acceptance and re-propulsive phases in gait along with the modification of spinal motor activity. METHODS: Ten subjects walked on a treadmill normally, then placed their feet flat on the ground at each step and finally walked on the balls of the feet. RESULTS: Our results show that when participants deviate from heel-to-toe rolling pattern strategy, the mechanical work increases on average 85% higher (F = 15.5; p < 0.001), mainly linked to a lack of propulsion at late stance. This modification of the mechanical power is related to a differential involvement of lumbar and sacral segment activation. Particularly, the delay between the major bursts of activation is on average 65% smaller, as compared to normal walking (F = 43.2; p < 0.001). CONCLUSION: Similar results are observable in walking plantigrade animals, but also at the onset of independent stepping in toddlers, where the heel-to-toe rolling pattern is not yet established. These indications seem to bring arguments to the fact that the rolling of the foot during human locomotion has evolved to optimise gait, following selective pressures from the evolution of bipedal posture.

A smart insole system capable of identifying proper heel raise posture for chronic ankle instability rehabilitation.

Heel raise is widely prescribed to patients with chronic ankle instability in order to strengthen the Peroneus Longus muscle (PL) which supports the weakened lateral collateral ligaments. While the exercise itself is intuitive, ankle orientation is of particular importance because heel raises performed with inversion do not well recruit the PL. This implies that proper execution is imperative and a means to assess heel raise training sessions is needed. In this study we present a smart insole system capable of identifying heel raise events and its corresponding rise, hold and drop phases, which allows for a more descriptive analysis. The results from our heel raise sessions, which consist of four different variants performed by five healthy subjects, suggest that medial-lateral foot pressure distribution and foot orientation are needed to differentiate heel raises performed with ankle eversion and inversion. We go further and substantiate that proper execution, detected by our system, indeed leads to increased PL activation by analyzing the electromyography signals. We believe that the proposed system may provide clinicians with invaluable information regarding onsite as well as at-home training and possibly, with biofeedback, serve as foundation for software as a medical device.

Soft-tissue vibration and damping response to footwear changes across a wide range of anthropometrics in running.

Different factors were shown to alter the vibration characteristics of soft-tissue compartments during running. Changing pre-heel strike muscle activation or changing footwear conditions represents two possibilities to influence the vibration response via frequency shift or altered damping. Associated with the study of muscle pre-tuning is the difficulty in quantifying clean experimental data for the acceleration of soft-tissue compartments and muscle activities in heterogeneous populations. The purpose of this study was to determine the vibration and pre-tuning response to footwear across a wide range of participants during running and establish and describe groups formed according to the damping coefficient. 32 subjects were used for further analysis. The subjects ran at a self-selected speed (5 min) on a treadmill in two different shoes (soft & hard), while soft-tissue accelerations and muscle activation at the gastrocnemius medialis were quantified. Damping coefficients, total muscle intensity and dominant vibration frequencies were determined. Anthropometrics and skinfold measurements of the lower limbs were obtained. According to the damping coefficient response to the footwear intervention, three groups were formed, with most runners (n = 20) showing less damping in the hard shoe. Total muscle intensity, anthropometrics, and dominant vibration frequency across footwear were not different for these three groups. Most runners (84.4%) used the strategy of adjusting the damping coefficients significantly when switching footwear. Despite damping being the preferred adjustment to changes in footwear, muscle pre-tuning might not be the only mechanism to influence damping as previously suggested. Future studies should focus on the subject-specific composition of soft-tissue compartments to elucidate their contribution to vibrations.

The single-leg heel raise does not predict maximal plantar flexion strength in healthy males and females.

INTRODUCTION: The single-leg heel raise test (SLHR) is commonly used in clinical settings to approximate plantar flexor strength, yet this is neither validated nor supported physiologically. The purposes of this study were to: determine (1) associations between SLHR repetitions, maximal plantar flexor strength, and reductions in strength; and (2) whether sex differences exist in performance of the SLHR. METHODS: Twenty-eight young, healthy participants (14 males,14 females, 19-30 years) performed repeated single-leg heel raises to task failure. Pre- and post-task measures included maximal voluntary isometric contractions (MVIC), and voluntary activation and contractile properties of the plantar flexor muscles, assessed using peripheral electrical stimulation of the tibial nerve. Surface electromyography was recorded for the medial and lateral gastrocnemius, soleus, and anterior tibialis muscles. RESULTS: The SLHR resulted in 20.5% reductions in MVIC torque (p<0.001). However, the number of SLHR repetitions was not correlated with either the baseline MVIC (maximal strength; p = 0.979) or the reduction in MVIC following the SLHR (p = 0.23). There were no sex differences in either the number of SLHR repetitions (p = 0.14), baseline MVIC torque (p = 0.198), or the reduction of MVIC (p = 0.14). MVIC decline was positively associated with the reduction in voluntary activation (r = 0.841, p<0.001), but was not associated with the change in twitch amplitude (p = 0.597). CONCLUSIONS: The SLHR was similar in young males and females yet was a poor predictor of maximal plantar flexor strength but evaluates performance fatigability of the lower extremity specific to dynamic contractions. The reduction in maximal strength at task failure was explained by reduced neural drive to the plantar flexor muscles in both males and females. IMPACT STATEMENT: SLHR performance is not a clinical assessment of plantar flexor strength but assesses dynamic lower extremity fatigability that is similar in males and females. Alternate clinical measures for maximal plantar flexion strength need to be developed.

Shorter heels are linked with greater elastic energy storage in the Achilles tendon.

Previous research suggests that the moment arm of the m. triceps surae tendon (i.e., Achilles tendon), is positively correlated with the energetic cost of running. This relationship is derived from a model which predicts that shorter ankle moment arms place larger loads on the Achilles tendon, which should result in a greater amount of elastic energy storage and return. However, previous research has not empirically tested this assumed relationship. We test this hypothesis using an inverse dynamics approach in human subjects (n = 24) at speeds ranging from walking to sprinting. The spring function of the Achilles tendon was evaluated using specific net work, a metric of mechanical energy production versus absorption at a limb joint. We also combined kinematic and morphological data to directly estimate tendon stress and elastic energy storage. We find that moment arm length significantly determines the spring-like behavior of the Achilles tendon, as well as estimates of mass-specific tendon stress and elastic energy storage at running and sprinting speeds. Our results provide support for the relationship between short Achilles tendon moment arms and increased elastic energy storage, providing an empirical mechanical rationale for previous studies demonstrating a relationship between calcaneal length and running economy. We also demonstrate that speed and kinematics moderate tendon performance, suggesting a complex relationship between lower limb geometry and foot strike pattern.

The role of the pressure information from the heel on the perception of the backward-leaning standing position.

The purpose of this study was to clarify the functional role of the heel pressure information for perceiving a backward-leaning position through a decrease in sensory information using local cooling on the heel in healthy participants (n = 11). The position of the center of pressure in the anteroposterior direction (CoPy position) while standing was represented as the percentage distance (%FL) from the hindmost point of the heel (0 %FL) in relation to the foot length. The most backward-leaning position was measured under cool-heel condition and normal-heel condition. The perceptibility of six reference positions (45 %FL, 40 %FL, 35 %FL, 30 %FL, 25 %FL, and 20 %FL) was evaluated with regard to the reproducibility of these positions under both heel conditions. The most backward-leaning position under cool-heel condition was located significantly further backward than that under normal-heel condition. The absolute error at 25 %FL under cool-heel condition was significantly larger than that under normal-heel condition. The sensory information from the heels may have a decisive meaning in the perception of the most backward-leaning position. At 25 %FL, there may be no other sources of sensory information for sensory reweighting aside from the heel pressure for position perception under cooled condition.

Agreement and consistency of five different clinical gait analysis systems in the assessment of spatiotemporal gait parameters.

BACKGROUND: Measuring gait function has become an essential tool in the assessment of mobility in aging populations for both, clinicians and researchers. A variety of systems exist that assess gait parameters such as gait cycle time, gait speed or duration of relative gait phases. Due to different measurement principles such as inertial or pressure sensors, accurate detection of spatiotemporal events may vary between systems. RESEARCH QUESTION: To compare the absolute agreement and consistency in spatiotemporal gait parameters among five different clinical gait analysis systems using different sensor technologies. METHODS: We compared two devices using inertial sensors (GaitUp & Mobility Lab), two devices using pressure sensor systems (GAITRite & Zebris) as well as one optical system (OptoGait). Twelve older adults walked at self-selected speed through a walkway integrating all of the above systems. Basic spatiotemporal parameters (gait cycle time, cadence, gait speed and stride length) as well as measures of relative phase (stance phase, swing phase, double stance phase, single limb support) were extracted from all systems. We used Intraclass Correlation Coefficients as measures of agreement and consistency. RESULTS: High agreement and consistency between all systems was found for basic spatiotemporal parameters, whereas parameters of relative phase showed poorer agreement and consistency. Overground measurement (GAITRite & OptoGait) showed generally higher agreement with each other as compared to inertial sensor-based systems. SIGNIFICANCE: Our results indicate that accurate detection of both, the heel-strike and toe-off event are crucial for reliable results. Systematic errors in the detection of one or both events may only have a small impact on basic spatiotemporal outcomes as errors remain consistent from step to step. Relative phase parameters on the other hand may be affected to a much larger extent as these differences lead to a systematic increase or reduction of relative phase durations.

Impact of high-heeled and sport shoes on multi-joint external load profile during walking.

BACKGROUND: Previous studies have analysed the effect of wearing high-heeled shoes (HHS) on gait analysis, balance and its relation to health. However, further research is needed to study its effect on the difference of chain reactions in the transfer of body impacts from the lower to the upper limbs. OBJECTIVES: The aims of the present research were: (a) to compare the effects of wearing HHS on impacts across body joints during walking with sport shoes (SS) as a reference, and (b) to examine such effects at different speeds. METHODS: Seven well-trained women completed this study. Incremental treadmill walking test were performed with two different footwear: SS and HHS. Inertial devices were used to quantify the chain reactions at selected anatomical lower limbs and trunk locations. Statistical analysis included the Wilcoxon test with ranges and Cohen's d effect size with percentage of differences. RESULTS: The highest values were found at the heel in both footwear and in both legs (SS: right =0.76 ± 0.27, left = 0.79 ± 0.27; HHS: right = 1.07 ± 0.38, left = 1.11 ± 0.41), while the lowest values were registered at lower and upper back. Furthermore, significant differences were found with the HHS load being higher at all locations (p< 0.05; %=𝑑𝑖𝑓𝑓 12.20-36.36%), influenced by the walking speed. In addition, a strong influence of footwear in the change of the laterality profile was found (p< 0.05). CONCLUSIONS: These findings suggest that the use of HHS increase the load on the lower limb and the trunk. Until reaching 5 km/h during walking, no significant differences were found between wearing HHS or SS in accelerometer load, producing exponential differences from this speed. The great between-subject variability implies that within-subject analysis is recommended, as it is more related to real clinical practice.

Reliability testing of the heel marker in three-dimensional gait analysis.

INTRODUCTION: In three-dimensional gait analysis, anatomical axes are defined by and therefore sensitive to marker placement. Previous analysis of the Oxford Foot Model (OFM) has suggested that the axes of the hindfoot are most sensitive to marker placement on the posterior aspect of the heel. Since other multi-segment foot models also use a similar marker, it is important to find methods to place this as accurately as possible. The aim of this pilot study was to test two different 'jigs' (anatomical alignment devices) against eyeball marker placement to improve reliability of heel marker placement and calculation of hindfoot angles using the OFM. METHODS: Two jigs were designed using three-dimensional printing: a ratio caliper and heel mould. OFM kinematics were collected for ten healthy adults; intra-tester and inter-tester repeatability of hindfoot marker placement were assessed using both an experienced and inexperienced gait analyst for 5 clinically relevant variables. RESULTS: For 3 out of 5 variables the intra-tester and inter-tester variability was below 2 degrees for all methods of marker placement. The ratio caliper had the lowest intra-tester variability for the experienced gait analyst in all 5 variables and for the inexperienced gait analyst in 4 out of 5 variables. However for inter-tester variability, the ratio caliper was only lower than the eyeball method in 2 out of the 5 variables. The mould produced the worst results for 3 of the 5 variables, and was particularly prone to variability when assessing average hindfoot rotation, making it the least reliable method overall. CONCLUSIONS: The use of the ratio caliper may improve intra-tester variability, but does not seem superior to the eyeball method of marker placement for inter-tester variability. The use of a heel mould is discouraged.

Correlation Between Gastrocnemius Tightness and Heel Pain Severity in Plantar Fasciitis.

BACKGROUND: It is known that there is an association between gastrocnemius tightness and plantar fasciitis, but this has never been quantified. The purpose of the study was to determine the correlation between gastrocnemius tightness and the severity of heel pain in plantar fasciitis. METHODS: Thirty-three patients were prescribed physiotherapist-directed gastrocnemius stretching exercises, a Strassburg Sock or night splint, and silicone heel insoles as required. Outcome measures included (1) gastrocnemius tightness, (2) 100-mm visual analog scale (VAS) for pain on the first steps in the morning, and (3) 100-mm VAS for the worst pain felt during the previous week. Gastrocnemius tightness was measured by the difference in maximal ankle dorsiflexion between knee bent and straight with a goniometer. RESULTS: The mean gastrocnemius tightness was 22 degrees at baseline compared with 9 degrees at the final follow-up (P < .01). A reduction in VAS for pain on the first steps in the morning and VAS for the worst pain felt during the previous week from baseline to final follow-up was observed (P < .01). Correlation analysis of 105 data points between gastrocnemius tightness and VAS for pain on the first steps in the morning was R = 0.757 (P < .001), and between gastrocnemius tightness and VAS for the worst pain felt during the previous week was R = 0.781 (P < .001). CONCLUSION: The study observed a strong, statistically significant correlation between gastrocnemius tightness and the severity of heel pain in plantar fasciitis. LEVEL OF EVIDENCE: Level IV, case series.

Back foot influence on dorsiflexion using three different positions of the weight bearing lunge test.

OBJECTIVES: To determine whether back foot (BF) position influences dorsiflexion range of motion (DFROM) during three different positions of the weight bearing lunge test (WBLT). DESIGN: Randomised, repeated measures design. SETTING: Sports clubs. PARTICIPANTS: 52 athletes participating in cutting and pivoting sports. MAIN OUTCOME MEASURES: DFROM was obtained using a WBLT in three different BF positions: BF heel in full contact with the floor, BF heel raised off the floor and BF was non weight bearing (NWB). All measurements were obtained using three methods: inclinometer at the tibial tuberosity, toe to wall distance and goniometer angle from the lateral malleolus to the fibula head. Differences between testing positions were determined using a repeated measures one-way ANOVA and reliability analysis was performed using the Intraclass Correlation Coefficient (ICC). RESULTS: DFROM was statistically significantly different for all three positions of the WBLT for each measurement technique (P < .001). These results were associated with large effect sizes for all BF positions and measurement techniques. Reliability ICC values were excellent for all measurements (ICC 0.94-0.99). CONCLUSIONS: Results show that DFROM differs depending upon the position of the BF during the WBLT. Further research is needed to establish the reproducibility of these three BF positions due to the variability observed.

What is the foot strike pattern distribution in children and adolescents during running? A cross-sectional study.

BACKGROUND: There is a lack of studies describing foot strike patterns in children and adolescents. This raises the question on what the natural foot strike pattern with less extrinsic influence should be and whether or not it is valid to make assumptions on adults based on the knowledge from children. OBJECTIVES: To investigate the distribution of foot strike patterns in children and adolescents during running, and the association of participants' characteristics with the foot strike patterns. METHODS: This is a cross-sectional study. Videos were acquired with a high-speed camera and running speed was measured with a stopwatch. Bayesian analyses were performed to allow foot strike pattern inferences from the sample to the population distribution and a supervised machine learning procedure was implemented to develop an algorithm based on logistic mixed models aimed at classifying the participants in rearfoot, midfoot, or forefoot strike patterns. RESULTS: We have included 415 children and adolescents. The distribution of foot strike patterns was predominantly rearfoot for shod and barefoot assessments. Running condition (barefoot versus shod), speed, and footwear (with versus without heel elevation) seemed to influence the foot strike pattern. Those running shod were more likely to present rearfoot pattern compared to barefoot. The classification accuracy of the final algorithm ranged from 80% to 88%. CONCLUSIONS: The rearfoot pattern was predominant in our sample. Future well-designed prospective studies are needed to understand the influence of foot strike patterns on the incidence and prevalence of running-related injuries in children and adolescents during running, and in adult runners.

Biomechanical Response to External Biofeedback During Functional Tasks in Individuals With Chronic Ankle Instability.

CONTEXT: Altered biomechanics displayed by individuals with chronic ankle instability (CAI) is a possible cause of recurring injuries and posttraumatic osteoarthritis. Current interventions are unable to modify aberrant biomechanics, leading to research efforts to determine if real-time external biofeedback can result in changes. OBJECTIVE: To determine the real-time effects of visual and auditory biofeedback on functional-task biomechanics in individuals with CAI. DESIGN: Crossover study. SETTING: Laboratory. PATIENTS OR OTHER PARTICIPANTS: Nineteen physically active adults with CAI (7 men, 12 women; age = 23.95 ± 5.52 years, height = 168.87 ± 6.94 cm, mass = 74.74 ± 15.41 kg). INTERVENTION(S): Participants randomly performed single-limb static balance, step downs, lateral hops, and forward lunges during a baseline and 2 biofeedback conditions. Visual biofeedback was given through a crossline laser secured to the dorsum of the foot. Auditory biofeedback was given through a pressure sensor placed under the lateral foot and connected to a buzzer that elicited a noise when pressure exceeded the set threshold. Cues provided during the biofeedback conditions were used to promote proper biomechanics during each task. MAIN OUTCOME MEASURE(S): We measured the location of center-of-pressure (COP) data points during balance with eyes open and eyes closed for each condition. Plantar pressure in the lateral column of the foot during functional tasks was extracted. Secondary outcomes of interest were COP area and velocity, time to boundary during static balance, and additional plantar-pressure measures. RESULTS: Both biofeedback conditions reduced COP in the anterolateral quadrant while increasing COP in the posteromedial quadrant of the foot during eyes-open balance. Visual biofeedback increased lateral heel pressure and the lateral heel and midfoot pressure-time integral during hops. The auditory condition produced similar changes during the eyes-closed trials. Auditory biofeedback increased heel pressure during step downs and decreased the lateral forefoot pressure-time integral during lunges. CONCLUSIONS: Real-time improvements in balance strategies were observed during both external biofeedback conditions. Visual and auditory biofeedback appeared to effectively moderate different functional-task biomechanics.

Plantar pressure distribution and wearing characteristics of three forefoot offloading shoes in healthy adult subjects.

Forefoot offloading shoes are used to reduce pressure on specific regions of the foot. Aim of the pressure reduction is to aid healing of the soft and bony tissues and prevent complications by treating foot disorders. A great variety of forefoot offloading shoes are available. In a first step to investigate the appropriate use of these footwear in orthopedic settings, we studied plantar pressure distribution and wearing characteristics of three forefoot offloading shoes namely the Mailand, OrthoWedge and Podalux in a healthy population. Twenty subjects walked in a randomized order wearing three forefoot offloading shoes and a reference shoe for six minutes. The Pedar system was used to measure the pressure in 7 regions. Peak pressure and pressure time integral were analyzed as measures of pressure distribution. Furthermore, wearing characteristics were addressed using a Numeric Rating Scale. Pressure distribution and wearing characteristics of the forefoot offloading shoes were compared to a reference shoe. The Mailand and OrthoWedge shoes significantly reduced peak pressure with more than 80% under the hallux and more than 45% under MTH1 (p<.001). The Podalux did not show significant peak pressure reduction under the forefoot compared to the reference shoe. Under the lesser toes, the MTH4-5 region and heel region the Podalux shoe showed even a significant increase in peak pressure (p=.001). Looking at wearing characteristics, the Podalux and reference shoe scored significantly better than the other two forefoot offloading shoes (p<.01). In this study the differences between different forefoot offloading shoes was assessed. The Mailand and OrthoWedge shoes gave the best pressure reduction in the forefoot but are less comfortable in use. The Podalux rocker shoe showed opposite results. Next step is a patient study to compare our results in a patient population.

Consensus for the Use of Weightbearing CT in the Assessment of Progressive Collapsing Foot Deformity.

RECOMMENDATION: There is evidence that the use of WEIGHTBEARING imaging aids in the assessment of progressive collapsing foot deformity (PCFD). The following WEIGHTBEARING conventional radiographs (CRs) are necessary in the assessment of PCFD patients: anteroposterior (AP) foot, AP or mortise ankle, and lateral foot. If available, a hindfoot alignment view is strongly recommended. If available, WEIGHTBEARING computed tomography (CT) is strongly recommended for surgical planning. When WEIGHTBEARING CT is obtained, important findings to be assessed are sinus tarsi impingement, subfibular impingement, increased valgus inclination of the posterior facet of the subtalar joint, and subluxation of the subtalar joint at the posterior and/or middle facet. LEVEL OF EVIDENCE: Level V, consensus, expert opinion.