Journal of Biomechanics 49 (2016) 1705–1710

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Journal of Biomechanics
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Gait ground reaction force characteristics of low back pain patients

with pronated foot and able-bodied individuals with and without
foot pronation
Nader Farahpour a,n, AmirAli Jafarnezhad a, Mohsen Damavandi b, Abbas Bakhtiari c,
Paul Allard d
a
Sport Biomechanics Department, Bu-Ali Sina University, Hamedan, Iran
b
Faculty of Physical Education and Sport Sciences, Hakim Sabzevari University, Sabzevar, Iran
c
Medical University of Hamedan, Hamedan, Iran
d
Department of Kinesiology, University of Montreal, Montreal, QC, Canada

art ic l e i nf o a b s t r a c t

Article history: The link between gait parameters and foot abnormalities in association with low back pain is not well
Accepted 29 March 2016 understood. The objective of this study was to investigate the effects of excessive foot pronation as well
as the association of LBP with excessive foot pronation on the GRF components during shod walking.
Keywords: Methods: Forty-five subjects were equally divided into a control group, a group of subjects with pronated
Ground reaction forces feet only, and another group with pronated feet and LBP. Ground reaction forces were analyzed during
Impulse shod walking.
Low back pain Results: Foot pronation without low back pain was associated with increased lateral-medial ground
Foot pronation reaction force, impulse, and time to peak of all reaction forces in heel contact phase (p o0.03). In low
Gait
back pain patients with pronated foot, greater vertical reaction forces (p¼ 0.001) and loading rate, and
time to peak on propulsion force were observed compared to pronated foot without low back pain group.
Impulse in posterior-anterior reaction force was smaller in the able-bodied group with normal foot than
in the other groups (po 0.05). Positive peak of free moments of the LBP group was significantly greater
than that in other groups (po 0.05). In conclusion, foot pronation alone was not associated with elevated
vertical ground reaction forces. While, low back pain patients with foot pronation displayed higher
vertical ground reaction force as well as higher loading rate. Present results reveal that gait ground
reaction force components in low back pain patients with pronated foot may have clinical values on the
prognosis and rehabilitation of mechanical LBP patients.
& 2016 Elsevier Ltd. All rights reserved.

1. Introduction
Although low back pain (LBP) attracts clinical attention due to
its high prevalence (Trainor and Wiesel, 2002), its etiology is still
unknown (Castro-Méndez et al., 2013). However, authors have
identified risk factors leading to LBP. Biomechanical abnormalities,
including stiffness of the joints and muscles of the lumbar spine,
asymmetrical spinal loading induced by poor postural muscle
function (Barwick et al., 2012; Chuter and de Jonge, 2012),
abnormal foot structure such as flat feet, ankle instability, and
n
Corresponding author. Tel.: þ 98 918 111 3816; fax: þ 98 81 3838 1421.
E-mail addresses: naderfarahpour1@gmail.com (N. Farahpour),
amiralijafarnezhad@gmail.com (A. Jafarnezhad),
mohsen.damavandi1@gmail.com (M. Damavandi),
Bakhtiariabbas75@yahoo.com (A. Bakhtiari), paul.allard@umontreal.ca (P. Allard).
excessive pronation (Bird and Payne, 1999; Botte, 1981) are among
the factors highly linked with mechanical LBP.
There is an interaction between the mechanical abnormalities
of the lower limb and the lower back segments (Bird and Payne,
1999; Botte, 1981). Throughout the gait cycle, excessive foot pro-
nation results in altered alignments of the tibia (Levinger et al.,
2012), femur (Souza et al., 2010), pelvis (Khamis and Yizhar, 2007),
and lumbar spine (Bird et al., 2003; Khamis and Yizhar, 2007;
Pinto et al., 2008), that lead to LBP.
Conversely, postural muscle weakness in the lower back (Bar-
wick et al., 2012; Chuter and de Jonge, 2012), and mechanical LBP
are associated with limited range of motion in the ankle as well as
an increased navicular drop (Brantingham et al., 2007). This makes
it difficult to conclude if foot abnormalities are the cause or con-
sequences of LBP. However, it is widely believed that abnormal
mechanical conditions of the lower limbs are highly linked with

http://dx.doi.org/10.1016/j.jbiomech.2016.03.056
0021-9290/& 2016 Elsevier Ltd. All rights reserved.
1706 N. Farahpour et al. / Journal of Biomechanics 49 (2016) 1705–1710

functional and mechanical LBP (Bird and Payne, 1999; Botte, 1981;
Kendall et al., 2014).
Among the foot abnormalities, excessive foot pronation has
received much clinical attention due to its high incidence (Castro-
Méndez et al., 2013; Khamis and Yizhar, 2007; Pinto et al., 2008).
Pronation or supination of the foot induced by the application of
lateral or medial wedge cause internal or external rotation of tibia
and femur, respectively (Duval et al., 2010; Pinto et al., 2008).
Internal rotation of the tibia and femur that induce an anterior
pelvis tilt (Betsch et al., 2012; Khamis and Yizhar, 2007), result in
abnormal lower limb kinematics (Kendall et al., 2014; Müller et al.,
2015; Seay et al., 2011), ground reaction forces (GRF) (Shum et al.,
2007), muscle activities (Hanada et al., 2011; van der Hulst et al.,
2010), and free moments (Bolgla et al., 2008; Li et al., 2001) during
gait leading to LBP (Cambron et al., 2011).
The free moment corresponds to the torque about the vertical axis
exerted on the foot and acting at the center of pressure (Holden and
Cavanagh, 1991). It is assumed that during running, the shock forces
transferred to the lumbar spine in individuals with pronated feet are
higher than that in those with supinated feet (Kendall et al., 2014). In
many LBP clinics, the treatment of foot abnormalities to improve gait
pattern (Willy et al., 2012) is recommended as a part of rehabilitation
protocol. However, recent reviews concluded that the link between
LBP and foot attitude, particularly excessive pronation, has not been
well documented (Kendall et al., 2014). To our knowledge, the
kinematics and kinetics characteristics during walking of LBP patients
with pronated feet have not previously been addressed. Many studies
were carried out by normal individuals fitted with a wedge to induce
a pronated foot anomaly (Betsch et al., 2012; Duval et al., 2010;
Khamis and Yizhar, 2007; Ntousis et al., 2013; Pinto et al., 2008).
Their conclusion can be difficult to apply to LBP subjects with
pronated feet.
The objective of this study was to investigate the effects of
excessive foot pronation on the GRF components in LBP patients
during shod walking. This study helps to understand the interac-
tion between LBP and foot pronation on altered biomechanics of
walking. It is hypothesized that a) GRF components are altered in
pronated foot subjects without LBP, b) the alteration of the GRF
components on LBP patients with pronated foot is greater than
that in pronated foot subjects without LBP.
(G*power) revealed that for a statistical power of 0.80 at an effect size of 0.80 with
an alpha level of 0.05 a sample size of at least 13 subjects was required (Faul et al.,
2007).
A subject was included in C group if he was between 20 to 30 years old, was
physically active, had normal feet, and did not have any musculoskeletal pain.
Individuals in the pronated feet groups were recruited from local clinics in
Hamedan city, Iran. A subject was included if he had a navicular drop of more than
10 mm (Lange et al., 2004), and a foot posture index of greater than 10 (Redmond et
al., 2006). Subject in the PF þLBP group had to fill out a visual analog pain scale and
the Roland-Morris disability questionnaire (Mousavi et al., 2006) (Table 1). A
subject was included in PFþ LBP group if the LBP index and disability were
430 mm and 410 mm respectively. Subject was excluded from the study if he had
any previous history of bone fractures, surgery, orthopedic disease (except foot
pronation for experimental groups, and LBP for PFþ LBP group), neuromuscular
problems, limb length discrepancies of greater than 5 mm, was feeling fatigue, and
if had heavy physical tasks or exercise during the past two days.
The age, height, body mass index (BMI), and low back pain index (for PF þ LBP
group) are summarized in Table 1. There was no significant difference between the
groups for age, height, mass, and body mass index (BMI). Subjects were all right
footed determined by kicking the ball. The protocol was approved by the ethical
committee of Medical Sciences university of Hamedan (p/16/35/9/5826–09/02/
2014). All subjects gave their informed consent to participate in the study.
2.2. Apparatus
A Vicon MX Motion Systems consisting of four T-series cameras (100 Hz) and a
Nexus-1.7.5 data capture software (Oxford metrics, UK) was used to quantify the
walking spatiotemporal variables. A preliminary calibration procedure was per-
formed (Vicon Motion Capture System, 2014. http://www.vicon.com/; Di Marco et
al., 2016) before the experiments. Sixteen reflective spherical markers (15 mm in
diameters) were used to identify the pelvis, thighs, legs, and feet. Marker locations
were determined according to the plug-in-gait model (Kadaba et al., 1990) that was
provided in Nexus software (Fig. 1). A force plate (Kistler AG, Winterthur, Swit-
zerland) synchronized with the Vicon system was used to record the GRF during
walking at 1000 Hz. The force plate was located at the center of the calibrated space
located in the middle of an 18 m walkway.
2.3. Task and procedure
Before the experiment, subjects were allowed to walk freely or do warm up
exercises for five minutes to become familiar with the experimental environment.

2. Methods

2.1. Subjects

In this study, one control group (C), a group of subjects with pronated feet only
(PF), and another group with pronated feet and LBP (PF þ LBP), including 15 male
subjects in each group, were studied. A prior statistical power analysis program

Table 1
Data are (mean 7 SD).

Variables Groups Sig.

C PF PF þLBP

Age (year) 26.00 7 2.87 25.33 7

2.69 25.26 7 2.89 0.74
Height (cm) 174.47 7 5.48 173.75 7
4.90 172.80 7 4.36 0.65
Mass (kg) 78.74 7 9.91 79.42 7
9.98 79.94 7 3.03 0.93
BMI (kg/m2) 25.88 7 3.16 26.30 7
3.04 26.81 7 1.50 0.64
LBP index (mm) 45.60 7 13.20 NA
Disability score 14.40 7 3.26 NA
Pain course (month) 22.40 7 8.60 NA
Navicular drop 5.46 7 0.83n 12.66 7 1.79 13.337 1.71 0.000
(mm) Fig. 1. Reflective markers attached on bony landmarks based on plug-in-gait
model. The landmarks are the anterior superior iliac spine (ASIS), posterior superior
Participant demographics, LBP index and disability score are presented for control iliac spine (PSIS), mid-thigh (MT), lateral condyle of femur (LCOF), mid-shank on
and experimental groups. NA ¼ not applicable. the lateral side (MSH), lateral malleolus (LMA), heel, and toe over the distal head of
n
Significant difference between the C and experimental groups. the second metatarsals bilaterally.
 N. Farahpour et al. / Journal of Biomechanics 49 (2016) 1705–1710 1707

The starting point for the walking trials was based on practice trials so that the
subject could take at least eight steps before entering the calibrated space and have
his right foot landing in the middle of the force plate. Five practice trials were
performed prior to the actual walking tests. Six repetition of shod walking through
the walkway were recorded. A trial was excluded if the foot was placed on the edge
of the force plate. All subjects wore the same shoe model. The GRF data were then
filtered using a fourth-order low-pass Butterworth filter with a 20 Hz cutoff
frequency.
The GRF along vertical (z), anterio-posterior (y), and lateral-medial (x) axes,
time to peak (TTP), vertical loading rate (Chao et al., 1983; Giakas et al., 1996;
Munro et al., 1987), impulses for all axes (Impuls z, Impuls y, impuls x) based on the
trapezoidal integration method (Robertson et al., 2013), and the free moment (Tz)
(Almosnino et al., 2009) were calculated. The GRF components in z axis were
reported for heel contact (FzHC), downfall (FzDF), and push-off (FzPO) phases. The
GRFs in y axis also were reported in heel contact (FyHC) and push-off (FyPO) phases.
For x axis also GRF during heel contact (FxHC), mid-stance (FxMS), and push-off
(FxPO) were reported. All GRF and free moment values were normalized with
respect to the body weight "BW" and "BW  Height", respectively.

2.4. Statistical analysis

Firstly, the normality of the variable distributions was verified using

Kolmogorov-Smirnov test. MANOVA test was used for between group comparisons.
The significance level was set at p o 0.05 for all analyses. Statistical analysis was
performed using SPSS16.

3. Results

The average walking speed, stance phase and step length were
not significantly different between groups (Table 2). Fig. 2 illus-
trates GRF components of a control subject in a single trial for the
three orientations. GRF variables for all groups are presented in
Table 3. GRF amplitudes in Fz, Fy, and Fx (except for FxPO) were
similar between C and PF groups (p 40.05). The FxPO in PF group
was about 80% greater than that in CG (p ¼0.000). The PFþ LBP
group displayed greater FzHC and FzPO by 6% (p ¼0.001) and 5%
(p ¼0.035) respectively than those in PF group. FxHC in PFþ LBP
group was smaller by 4% (p¼ 0.004) than those in PF group.
Fig. 2. A time-normalized sample traces of the ground reaction forces of a normal
PFþ LBP group also displayed greater FzHC, FxPO and FyPO by 6%, 8%, subject during walking. Reaction forces and impulse area in all axes and vertical
and 12% respectively, than those in C group (po 0.05). loading rate are displayed.
Table 4 shows the TTP in all groups. TTP for FzHC, FxHC, and FyHC
in PF group were significantly greater by 19% (p ¼0.019), 28%
Table 3
(p ¼0.003), and 103% (p¼ 0.000) than that in CG. TTP for FyHC in
Data are (mean 7SD).
PFþ LBP group was significantly smaller than that in PF group by
50% (p¼ 0.000). Other TTP variables between PF and PFþ LBP GRF Groups
groups were not statistically different (p 40.05). PF þLBP group
C PF PFþ LBP
displayed greater FxHC (by 26%), and smaller FxMS (by 28%) and
FxPO than those in C group (p o0.05). TTP on FzD.F and FzPO was FzHC 106.127 3.70ɑ 107.677 5.75¥ 114.577 5.16ɑ¥
similar in all groups (p4 0.05). Other between groups' differences FzMS 82.687 2.98 83.42 7 4.89 83.05 7 4.16
on TTP variables were not statistically significant. FzPO 111.977 4.59 107.63 7 5.63¥ 112.687 5.44¥
FxHC 9.917 2.26 13.42 7 3.10¥ 8.517 5.55¥
Loading rate of PF group was relatively smaller than that of the
FxMS 7.337 2.01 8.487 1.62 8.45 7 1.69
other groups. However, the loading rate of PF group was sig- FxPO 5.52 7 2.88*ɑ 9.977 2.05* 9.78 7 2.50ɑ
nificantly smaller than that of PF þLBP group (p ¼0.020) (Fig. 3). z FyHC 27.577 4.26 30.487 2.70 32.22 7 7.38
and x impulses in PF and C groups were similar. However, y FyPO 34.117 3.85ɑ 36.707 5.06 38.107 3.69ɑ
impulse of PF group was statistically greater than that of C group
GRF of Z, Y, and X axes in different stance phases for control and experimental
groups are presented.
Table 2 ɑ
Significant difference between PF and PFþ LBP groups.
Data are (mean7 SD). ¥
Significant difference between PF and PFþ LBP groups.
*
Significant difference between C and PF groups.
Variables Groups Sig.

C PF PF þLBP
(p ¼0.015). In PF and PFþLBP groups similar impulses were
Cadence (steps/minutes) 103.017 7.13 100.29 7 8.30 101.89 77.85 0.63
Step time (s) 0.617 0.05 0.62 7 0.09 0.59 70.08 0.7 observed in all axes. Similarly, the differences between C and
Single support (s) 0.417 0.05 0.40 7 0.04 0.43 70.05 0.14 PFþLBP groups were also significant only on Y axis (p¼ 0.033)
Step length (m) 0.78 7 0.08 0.727 0.08 0.78 70.15 0.17 (Fig. 4).
Walking speed (m/s) 1.20 7 0.14 1.167 0.07 1.18 70.09 0.6
The peak positive free moment (% BW  H) between C and PF
Spatiotemporal parameters of gait for control and experimental groups are groups was similar. But, PFþLBP group displayed significantly
presented. greater positive free moment than PF and C groups (p ¼0.046). The
1708 N. Farahpour et al. / Journal of Biomechanics 49 (2016) 1705–1710

Table 4
Data are (mean 7 SD).

GRF Groups

C PF PF þLBP

FzHC 183.56 7 15.23* 217.337 48.36* 190.44 725.20

FzMS 351.337 19.43 368.007 55.84 347.33724.11
FzPO 569.107 34.58 583.56 7 58.87 565.76 738.81
FxHC 50.22 7 6.36*ɑ 64.007 10.25* 63.12 713.86ɑ
FxMS 282.007 91.55ɑ 217.32 7 79.92 204.65 749.58ɑ
FxPO 625.55 7 88.09ɑ 574.45 7 81.04 551.55 735.58ɑ
FyHC 139.54 7 15.25ɑ 283.09 7 25.59*¥ 144.22 715.65¥
FyPO 640.897 31.22 663.997 71.56 640.66 741.98
Fig. 5. Negative (abductors) and positive (adductors) peaks of free moment curve
The time to peak of GRF components are presented for control and experimental in stance phase of level walking in control and experimental groups. *: Significant
groups. difference (p o 0.05).
*
Significant difference between C and PF groups.
ɑ
Significant difference between C and PFþ LBP groups. due to foot pronation. Plantar flexor invertors play significant roles in
¥
Significant difference between PF and PFþ LBP groups.
medial acceleration of the center of mass on late stance (Pandy et al.,
2010). The elevated GRF components result in higher compressive load
to the lumbar discs (Betsch et al., 2012; Duval et al., 2010; Khamis and
Yizhar, 2007; Pinto et al., 2008). Authors have postulated that reducing
foot pronation by a foot orthosis could contribute to the repositioning
of the tibia and femur in their normal condition, optimizing the
mechanical properties of the lower limb joints (Castro-Méndez et al.,
2013; Hsu et al., 2014; Kendall et al., 2014). This could reduce spinal
load as well as the low back pain.
In present study, PF þLBP group displayed greater FzHC and FzPO
but smaller FxHC than those in PF group. In PFþ LBP, smaller TTP of
the FyHC, and higher loading rate and free moment were observed
than those in PF group. These results support the second
hypothesis of this study. It is difficult to determine whether the
LBP is developed by foot pronation alone since subjects in PF
group did not have LBP.
The elevated GRF components in PFþ LBP subjects compared to
Fig. 3. Vertical loading rate in stance phase of level walking in control and PF group could be due to some possible mechanical factors which
experimental groups. *: Significant difference (p o 0.05).
occurred with foot pronation, such as a greater knee extension at
heel contact phase (Müller et al., 2015), trunk stiffness (Lamoth et
al., 2006), problems in adjusting pelvis–thorax coordination
(Müller et al., 2015; Seay et al., 2011), or altered hamstring muscle
coordination and activation levels (Vogt et al., 2003). It is not
possible to conclude if this higher vertical GRF is the cause or
effect of LBP. Elevated GRF in association with diminished activity
of quadriceps femoris (Hart et al., 2010) could exacerbate low
back pain.
In present study, the subjects in PFþLBP group displayed
higher propulsion force and loading rate compared to the subjects
in PF group. We did not find other studies addressing this issue.
Fig. 4. Impulse values in stance phase of level walking in control and experimental
groups. *: Significant difference (p o0.05).
Probably, a portion of the increased propulsion force could be to
oppose the excessive anterior tilt and anterior rotation of the
negative peak free moment was similar in all groups (p 40.05) pelvic associated with foot pronation (Cambron et al., 2011). The
(Fig. 5). increased propulsion force associated with stiffer trunk (Seay et al.,
2011) also could be another risk factor for low back pain. Recently,
Hart et al. (2010) showed that quadriceps femoris muscle in low
back pain patients was less activated than that in a healthy
4. Discussion population without back pain (Hart et al., 2010). The activity of
quadriceps femoris is assumed to contribute to the energy
It was hypothesized that a) foot pronation affects GRF compo- absorption at the initial heel contact to diminish the ground
nents during walking, and b) the alteration of the GRF components reaction force (Liikavainio et al., 2007). This evidence with the fact
on LBP patients with pronated foot is greater than that in pronated that the vertical GRF in PFþ LBP group was higher than that in PF
foot subjects without LBP. group, could partially explain the mechanism of LBP development
This study is the first to identify that FxPO amplitude and TTP of in PFþLBP group.
FzHC, FxHC, FyHC, as well as the propulsion impulse in PF group were Present study showed that the loading rate in PF group was
significantly higher than those in C group. This proves the first smaller than that in PFþ LBP group. This is in agreement with Hart
hypothesis of this study and reveals that, the foot pronation alters the et al. (2010). Earlier, authors have postulated that the elevated
GRF components. The elevated FxPO in PF group can be explained in vertical loading rate is considered as a risk of stress fractures
part by the altered invertors and evertors' length-tension relationship (Crowell and Davis, 2011; Pohl et al., 2008; Zadpoor and Nikooyan,
 N. Farahpour et al. / Journal of Biomechanics 49 (2016) 1705–1710
2011; Zifchock et al., 2006) and patellofemoral pain (Davis et al.,
2010).
The TTP values of PF þLBP group on all GRF components were
closer to the C group than to PF group. Therefore, it seems that TTP
of GRF variables does not have clinical importance for gait analysis
of LBP patients with pronated foot.
In present study, the peak positive free moment in PFþ LBP
group was significantly greater than that of the PF and C groups.
This may suggest that excessive free moment may facilitate the
occurrence of low back pain in those pronated foot subjects who
are at risk of low back pain. Free moment is described as the foot
abd/adduction (Nigg, 1986), or torsional force (Almosnino et al.,
2009; Creaby and Dixon, 2008; Holden and Cavanagh, 1991) dur-
ing stance phase. Earlier, the asymmetrical free moments during
walking are observed in girls with idiopathic scoliosis (Giakas et
al., 1996).
This study has few limitations that must be considered. The
number of participants of the study was relatively small. However,
the study had sufficient power on statistical tests to detect the
group differences. Further investigations are needed to evaluate
the effects of the walking speed and the slope of the walking level.
This study did not address the muscle activities during gait in
different groups. Combination of kinematics with electrical activ-
ities of the effective muscles on walking may bring additional
insights to the investigation of the risk factors in LBP patients with
pronated foot. Further studies are suggested to combine the
measurements of different muscle activities with kinetic analysis
during gait.
5. Conclusions
In subjects with foot pronation without LBP, vertical and
posterior-anterior GRF were normal; but, lateral-medial GRF in
push-off phase was altered. In LBP patients with pronated foot, the
vertical GRF during heel contact and push-off, loading rate, and
the adductor free moments were higher than those in pronated
foot subjects without LBP. Whether these altered variable are the
cause of LBP need to be assessed in further studies.
It is recommended to include gait parameters measurements in
the evaluation of the mechanical LBP patients. For LBP patients
with pronated foot, lower values in the GRF, loading rate and the
adductor free moments could be indicative of lower back pain
reduction.
Conflict of interest statement
All authors declare no conflict of interests regarding the pub-
lication of this manuscript.
Acknowledgments
Authors gratefully thank Dr Ali Saleh, radiologist, for his valu-
able assistance. We also gratefully thank patients for their parti-
cipation in this study. Authors did not receive any financial sup-
port for this study.
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