International Journal of Athletic Therapy and Training, 2019, 24, 229-234

https://doi.org/10.1123/ijatt.2018-0107
© 2019 Human Kinetics, Inc. RESEARCH REPORT

Effects of Real-Time Video Feedback on Plantar Pressure Measures

in Individuals With Chronic Ankle Instability During Walking
Anna M. Ifarraguerri, BS, Danielle M. Torp, MS, ATC, Abbey C. Thomas, PhD, ATC, and
Luke Donovan, PhD, ATC
University of North Carolina at Charlotte

Individuals with chronic ankle instability (CAI) have been shown to have increased lateral plantar pressure during walking which
is thought to contribute to symptoms associated with CAI. The objective of this study was to determine whether real-time video
feedback can reduce lateral plantar pressure in individuals with CAI. Twenty-six participants with CAI completed 30 s of
treadmill walking while plantar pressure was measured using an in-shoe plantar pressure system (baseline). Next, participants
completed an additional 30 s of treadmill walking while receiving video feedback (VID FB). During the VID FB condition,
participants had a significant decrease in medial forefoot peak pressure and medial midfoot pressure-time integral; however, both
changes were associated with small effect sizes. Real-time video feedback did not reduce lateral plantar pressure in individuals
with CAI; therefore, other gait retraining strategies should be considered when treating patients with CAI.

Keywords: biofeedback, biomechanics, gait, lateral ankle sprain

Lateral ankle sprains (LAS) are the most frequently Visual feedback (cameras or mirrors) is a common
sustained musculoskeletal injury in sport and recreational clinical intervention to alter biomechanics given the low
activities.1,2 Approximately 40% of individuals with a cost and ease of implementation. Furthermore, visual
history of LAS develop a condition known as chronic feedback has been shown to be effective at improving
ankle instability (CAI),3 which is characterized by repet- knee and hip kinematics during running in patients with
itive ankle sprains or feelings of instability lasting greater other chronic pathologies such as patellofemoral pain
than 1 year after initial injury.4 Individuals with CAI often (PFP).17,18 Given the successes of the aforementioned
exhibit a spectrum of mechan- studies, visual feedback may be a beneficial intervention
ical and functional impair- to improve ankle biomechanics in patients with CAI.
KEY POINTS ments,4 one of which is However, at this time, the effects of real-time visual
altered gait biomechanics.5–11 feedback, specifically with video cameras, on ankle
Real-time video feedback caused On average, individuals biomechanics during walking in individuals with CAI
▸ inconsistent alterations in gait in
patients with chronic ankle
with CAI have reduced dorsi-
flexion,8 increased inver-
has not been determined.
Prior to incorporating visual feedback to improve
instability. sion,7,9 increased lateral gait into a rehabilitation program for individuals with
peak plantar pressure,12,13 CAI, we must first determine whether individuals with

▸
Efficacy of other clinician cues and a more laterally-deviated CAI incorporate positive motor adaptations in response
during video feedback should be center of pressure (COP) dur- to visual feedback during walking. Therefore, the pur-
determined. ing walking when compared pose of this study was to evaluate whether participants
to individuals with no LAS with CAI can improve their biomechanics during tread-
Other gait retraining interventions history.12,13 These modified mill walking by reducing the lateral plantar pressure of
▸ should be considered when treating
patients with chronic ankle
gait patterns are thought to
contribute to the repetitive
their injured limb in response to receiving real-time video
feedback. We hypothesized that, in response to real-time
instability.
ankle sprains and lasting feel- video feedback, participants with CAI would be able to
ings of instability associated decrease peak pressure and pressure-time integral on the
with CAI due to the ankle lateral aspect of their foot during treadmill walking.
being placed in a position that mimics the mechanism
of injury of a LAS.14 Furthermore, prospective studies
concluded that individuals with a more laterally-deviated Methods
COP and increased inversion during gait are at a greater
risk of sustaining a LAS15 and developing ankle osteoar- Study Design
thritis.16 These findings15,16 demonstrate the necessity to
improve altered gait patterns following a LAS or in We performed a laboratory study observing changes
individuals with CAI. in plantar pressure measures (contact area, contact time,
peak pressure, and pressure-time integral) across nine
Ifarraguerri, Torp, Thomas, and Donovan are with the University of North Carolina at Charlotte, regions of the foot (medial heel, lateral heel, medial
Charlotte, NC. Donovan (ldonova2@uncc.edu) is corresponding author. midfoot, lateral midfoot, medial forefoot, central
229
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230 Ifarraguerri et al.
forefoot, lateral forefoot, great toe, and toes 2–5) between two
conditions: (1) no video feedback (Baseline) and (2) real-time
video feedback (VID FB) during treadmill walking in participants
with CAI.
Participants
Twenty-six adults with CAI participated in this study (Table 1). As
recommended by the International Ankle Consortium,19 in order to
participate in the study, participants met the following criteria
(a) presented with a history of more than one LAS with the initial
sprain taking place more than 1 year prior to the start of the study;
(b) current self-reported functional deficits determined by a score of
<85% on the Foot and Ankle Ability Measure (FAAM) Sport scale
and a score ≥11 on the Identification of Functional Ankle Instability
scale (IdFAI).19 Individuals were excluded from the study if they
(a) had a LAS within 6 weeks prior to the start of the study, (b) have
had ankle surgery or ankle fracture, or (c) currently have symptoms
from another known lower extremity injury or pathology. Partici-
pants provided consent prior to participation in the study. The study
was approved by the institutional review board at the University of
North Carolina at Charlotte.
Instrumentation
Plantar Pressure. Plantar pressure was recorded using an in-shoe
plantar pressure insole system (Pedar-x; Novel Inc., St Paul, MN)
with a sampling rate of 100 Hz. Participants used a neutral athletic
shoe fitted according to foot size (ASICS Gel Contender 4; ASICS
America Corp., Irvine, CA).
Video Feedback Device. Real-time video feedback was implemen-
ted by using a commercially-available high-definition (1080p) camera
(Hero 5; GoPro Inc., San Mateo, CA), sampling at 60 frames/s. The
video camera was connected to a flat screen television (55” LED-
1080p; Samsung Inc., San Jose, CA) via an high-definition multimedia
interface (HDMI) cord. The video camera was placed on a tripod
behind a treadmill at a standard distance (30 cm) and height (42 cm).
Camera distance and height were selected because it provided the
clearest image of the foot during walking. The television was mounted
to the wall with the bottom of the television being 155 cm above the
ground and 90 cm away from the front of the treadmill. A live video
feed of the person walking was projected on to the television screen,
Table 1 Participant Demographics and Ankle Sprain
History (n = 26)
Demographic Mean ± SD
Sex (male: female) 11: 15
Age (years) 20.9 ± 2.4
Height (cm) 170.2 ± 10.2
Mass (kg) 78.4 ± 22.1
Ankle sprains of involved limb 4.9 ± 4
Time since last sprain (months) 25.9 ± 24.6
Time since first sprain (years) 7.5 ± 3.8
Foot and Ankle Ability Measure ADL (%) 81.6 ± 8.6
Foot and Ankle Ability Measure Sport (%) 67.6 ± 10.9
Identification of Functional Ankle Instability scale 21.2 ± 3.7
Abbreviation: ADL = activities of daily living.
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enabling the participant to observe the posterior aspect of his/her foot
while walking. Video feedback set-up can be found in Figure 1.
Procedures
Procedures previously detailed were followed.14,20,21 Following
informed consent, eligible participants were fitted for standard,
neutral shoes with the plantar pressure insoles inserted into the
shoe. Once fitted for the shoes, participants were instructed to walk
on the treadmill at a comfortable pace that they perceived as their
normal walking speed. Once the participant identified that he/she
was walking at his/her normal speed, 30 s of plantar pressure were
collected (baseline). Next, the camera was turned on and the
participant could see the affected limb on the television in front
of them. The participant was then instructed to “walk in a manner
where you can no longer view the outside or inside of your foot on
the television screen while you walk”. These instructions were
provided to promote a neutral position of the foot and to inhibit the
participant from overcorrecting their foot placement. Our instruc-
tions during the VID FB condition were developed based on
common cues provided within the clinical setting and from the
studies that aimed to improve knee biomechanics in patients with
PFP.17,18 Furthermore, pilot data prior to the start of the study
suggested that a neutral foot during gait corresponded with less
lateral plantar pressure when compared to a non-neutral foot. After
the participant indicated that he/she is walking according to the
instructions, 30 s of plantar pressure was collected (VID FB).
Data Reduction
Peak Pressures. In order to provide a comprehensive plantar
pressure profile during each condition,13,14,20,21 the mean of the
middle 10 consecutive steps for contact area, contact time, peak
pressure, and pressure time integral of the involved limb across all
nine regions of the foot were calculated (Novel Database Pro 1/14
and Automask software packages; Novel Inc, St Paul, MN).13,14,20,21
Statistical Analysis. Data were analyzed using Excel 2016
(Microsoft, Redmond, WA). Paired t-tests were performed for each
dependent variable (condition: baseline and VID FB) for each
measure of plantar pressure across all nine regions of the involved
limb, with the level of significance set a priori at p ≤ .05 for all
Figure 1 — Visual feedback was provided to the participant by placing
a video camera behind the treadmill. The camera was connected to a
television located in front of the treadmill via high-definition multimedia
interface (HDMI) cord. This set-up allowed the participant to walk on the
treadmill while viewing their ankle biomechanics on the television.
 Effects of Real-Time Visual Feedback on Gait 231

analyses. Cohen d effect sizes and associated 95% confidence
intervals (CIs) were calculated and interpreted as ≥0.80 large, 0.50–
0.79 moderate, 0.20–0.49 small, and <0.20 trivial. Results were
considered significant and clinically meaningful if p ≤ .05 and
effect sizes were moderate to large with CIs that did not cross
zero.22
As an exploratory analysis, we identified responders and
nonresponders by using previously-established coefficients of
repeatability (CR) for the in-shoe plantar pressure system used
within our investigation. The CR, also referred to as the smallest
real difference, is a measure of absolute reliability and can be
expressed as a percentage of the mean or as the same units as the
measure of interest.23 The CR identifies what outcome we would
expect in a measure 95% of the time if that measure were repeated
on the same population.23 Values from a measure greater than the
established CR would indicate a true change in the outcome
measure. The study by Putti et al.24 found that, on average, the
lateral column of the foot for peak plantar pressure had a CR of
approximately 5%; therefore, participants who had ≥5% change in
peak plantar pressure within the lateral midfoot and/or forefoot
would be identified as a responder. Independent t-tests were
performed to determine whether differences in baseline peak
pressure within the lateral midfoot and forefoot regions existed
between the responders and nonresponders. In the event of signifi-
cance (p ≤ .05), binary logistic regression models would be created
to determine whether baseline peak pressure within the respective
region of the foot can predict whether a participant responded to
VID FB.
Results
Condition comparison of contact area, contact time, peak pressure,
and pressure-time integral across all nine regions of the foot can be
found in Tables 2–5, respectively. A significant reduction in peak
pressure within the medial forefoot (mean difference: −15.7 kPa;
p = .04) and in pressure-time integral within the medial midfoot
(mean difference: −4.7 kPa*s; p = .04) was observed during the
VID FB condition; however, these significant changes were asso-
ciated with small effect sizes and associated 95% CIs that crossed 0.
All other plantar pressure measures between conditions were not
significant (p > .05).
In addition, 19/26 (≈ 73%) participants had a change in peak
pressure of the lateral aspect of their foot between conditions that
exceeded 5%. Of those 73% that we would consider to have had a
true change in peak plantar pressure during the VID FB condition,
52.6% decreased their lateral peak plantar pressure, while 47.4%
increased their lateral peak plantar pressure. Considering the near
equal distribution of individuals who responded to the VID FB, we
further classified the participants as either “responders with a
decrease” or “responders with an increase” in peak plantar pressure.
There were no significant differences in baseline peak plantar
pressure within the lateral midfoot and lateral forefoot regions
when comparing responders (mean ± SD: lateral midfoot = 114.9 ±
20.8 kPa; lateral forefoot = 156.9 ± 29 kPa) to nonresponder (lateral
midfoot = 110.9 ± 11 kPa; lateral forefoot = 162 ± 36.5 kPA)
or when comparing responders with a decrease in peak pressure
(mean ± SD: lateral midfoot = 116.2 ± 17.6 kPa; lateral forefoot =
155 ± 24.1 kPa) to responders who had an increase in peak pressure
(mean ± SD: lateral midfoot = 112.6 ± 26.7 kPa; lateral forefoot =
158.9 ± 34.6 kPa).
Discussion
The purpose of this study was to determine if lateral plantar
pressure can be reduced by receiving real-time video feedback
during treadmill walking in participants with CAI. We found no
significant within-condition alterations to the lateral plantar pres-
sure between the baseline and VID FB conditions. Although
significant reductions in peak pressure and pressure-time integral
within the medial forefoot and midfoot regions were observed,
these changes were associated with small effect sizes and 95% CIs
that crossed 0, suggesting that these alterations are not clinically
meaningful. When examining our results in conjunction with
previously-established CR, it appears real-time video feedback
can modulate movement patterns in individuals with CAI, just
not in a consistent direction. Furthermore, baseline peak pressure
within the lateral midfoot and lateral forefoot were no different
between participants who experienced meaningful decreases in
lateral peak pressure and participants with meaningful increases in
lateral peak pressure during VID FB. Therefore, prior to advocating
for the use of VID FB within a clinical setting, more effective cues
and evaluation strategies must be established.

Table 2 Contact Area Measured in Centimeters Squared and the Nine Regions of the Foot During Treadmill
Walking During Baseline and Visual Feedback Conditions
Mean ± SD Mean Difference Paired T-Test Effect Size (LL, UL)
Region of the Foot Baseline Visual Visual–Baseline p-Value Visual – Baseline
Medial heel 22.5 ± 3.9 22.3 ± 3.9 −0.1 .06 −0.04 (−0.58, 0.51)
Lateral heel 20.5 ± 3.7 20.2 ± 3.5 −0.3 .11 −0.08 (−0.62, 0.47)
Medial midfoot 21.0 ± 6.9 21.1 ± 6.4 0.1 .24 0.01 (−0.53, 0.56)
Lateral midfoot 26.8 ± 4.5 26.6 ± 4.2 −0.2 .34 −0.05 (−0.59, 0.50)
Medial forefoot 12.8 ± 2.5 12.7 ± 2.5 −0.1 .92 −0.03 (−0.57, 0.52)
Central forefoot 15.1 ± 2.2 15.0 ± 2.2 −0.1 .18 −0.02 (−0.57, 0.52)
Lateral forefoot 14.5 ± 2.2 14.5 ± 2.2 −0.1 .51 −0.04 (−0.58, 0.51)
Great toe 11.0 ± 1.9 11.0 ± 1.8 0.1 .32 0.03 (−0.52, 0.57)
Lesser toes 18.7 ± 3.2 18.9 ± 3.2 0.2 .19 0.06 (−0.48, 0.60)
Abbreviations: LL = lower limit of 95% confidence interval; UL = upper limit of 95% confidence interval.
Negative effect size represents smaller contact area during the visual feedback condition.

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Table 3 Contact Time Measured in Milliseconds and the Nine Regions of the Foot During Treadmill Walking During
Baseline and Visual Feedback Conditions
Mean ± SD Mean Diff Paired T-Test Effect Size (LL, UL)
Region of the Foot Baseline Visual Visual–Baseline p-Value Visual – Baseline
Medial heel 615.3 ± 129.6 555.3 ± 123.3 −60.0 .13 −0.46 (−1.01, 0.09)
Lateral heel 670.8 ± 141.4 621.4 ± 180.7 −49.4 .22 −0.35 (−0.90, 0.20)
Medial midfoot 742.6 ± 135.4 719.7 ± 139.6 −23.0 .14 −0.17 (−0.71, 0.38)
Lateral midfoot 797.1 ± 130.4 792.1 ± 125.5 −5.0 .71 −0.04 (−0.58, 0.51)
Medial forefoot 714.1 ± 116.3 674.7 ± 125.2 −39.3 .07 −0.34 (−0.89, 0.21)
Central forefoot 740.9 ± 127.3 715.5 ± 115.2 −25.4 .13 −0.20 (−0.74, 0.35)
Lateral forefoot 774.1 ± 134.7 749.9 ± 118.6 −24.2 .13 −0.18 (−0.72, 0.36)
Great toe 733.7 ± 118.2 722.0 ± 117.2 −11.6 .39 −0.10 (−0.64, 0.45)
Lesser toes 734.8 ± 139.4 715.8 ± 123.7 −19.0 .50 −0.14 (−0.68, 0.41)
Abbreviations: LL = lower limit of 95% confidence interval; UL = upper limit of 95% confidence interval.
Negative effect size represents shorter contact time during the visual feedback condition.

Table 4 Peak Pressure Measured in Kilopascals and the Nine Regions of the Foot During Treadmill Walking During
Baseline and Visual Feedback Conditions
Mean ± SD Mean Diff Paired T-Test Effect Size (LL, UL)
Region of the Foot Baseline Visual Visual–Baseline p-Value Visual – Baseline
Medial heel 166.2 ± 39.1 159.0 ± 50.1 −7.2 .70 −0.18 (−0.73, 0.36)
Lateral heel 155.0 ± 26.4 148.7 ± 39.0 −6.3 .67 −0.24 (−0.78, 0.31)
Medial midfoot 112.3 ± 21.9 104.3 ± 19.4 −8.0 .12 −0.36 (−0.91, 0.18)
Lateral midfoot 117.3 ± 18.7 112.3 ± 21.3 −5.1 .55 −0.27 (−0.82, 0.28)
Medial forefoot 187.3 ± 50.7 171.6 ± 40.5 −15.7 .04* −0.31 (−0.86, 0.24)
Central forefoot 188.0 ± 40.7 179.0 ± 40.7 −9.0 .22 −0.22 (−0.77, 0.32)
Lateral forefoot 161.7 ± 31.2 159.0 ± 37.3 −2.7 .74 −0.09 (−0.63, 0.46)
Great toe 217.1 ± 45.1 227.3 ± 58.4 10.2 .39 0.23 (−0.32, 0.77)
Lesser toes 179.5 ± 43.5 177.1 ± 36.4 −2.4 .74 −0.05 (−0.60, 0.49)
Abbreviations: LL = lower limit of 95% confidence interval; UL = upper limit of 95% confidence interval.
Negative effect size represents a decrease in peak plantar pressure during the visual feedback condition. *Indicates statistically significant difference between conditions
(p ≤ .05).

Table 5 Pressure Time Integral Measured in Kilopascals Times Seconds and the Nine Regions of the Foot During
Treadmill Walking During Baseline and Visual Feedback Conditions
Mean ± SD Mean Diff Paired T-Test Effect Size (LL, UL)
Region of the Foot Baseline Visual Visual–-Baseline p-Value Visual – Baseline
Medial heel 56.8 ± 12.7 48.8 ± 14.5 −8.1 .08 −0.63 (−1.19, −0.08)
Lateral heel 55.2 ± 13.1 47.7 ± 15.8 −7.5 .09 −0.58 (−1.13, −0.02)
Medial midfoot 51.8 ± 12.3 47.1 ± 12.2 −4.7 .04* −0.38 (−0.93, 0.17)
Lateral midfoot 61.5 ± 13.6 58.2 ± 15.8 −3.3 .65 −0.24 (−0.79, 0.30)
Medial forefoot 63.8 ± 17.6 61.5 ± 18.8 −2.3 .29 −0.13 (−0.67, 0.41)
Central forefoot 63.1 ± 13.5 64.0 ± 17.8 0.9 .96 0.07 (−0.48, 0.61)
Lateral forefoot 59.0 ± 14.2 60.9 ± 17.2 2.0 .42 0.14 (−0.41, 0.68)
Great toe 70.5 ± 17.7 77.4 ± 26.5 6.9 .32 0.39 (−0.16, 0.94)
Lesser toes 58.4 ± 14.1 61.9 ± 17.9 3.6 .30 0.25 (−0.29, 0.80)
Abbreviations: LL = lower limit of 95% confidence interval; UL = upper limit of 95% confidence interval.
Negative effect size represents a decrease in pressure time integral during the visual feedback condition. *Indicates statistically significant difference between conditions
(p ≤ .05).

232 IJATT Vol. 24, No. 6, 2019

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Clinical Interpretation
Clinicians should use caution when implementing real-time video
feedback to improve foot and ankle biomechanics in patients with
CAI. The inconsistencies across our results may be attributed to the
cue provided to the participants. The goal of the cue was to promote
a neutral foot, when in reality, the majority of participants either
drastically shifted their plantar pressure medially or laterally. As a
result, mean differences between conditions were close to 0,
indicating no change for all measures of plantar pressure. Clin-
icians should avoid instructing patients to walk in a neutral foot
position until further investigations are completed to develop the
most appropriate cue to improve gait in patients with CAI. In
addition, based on a recent review paper,25 visual feedback is by far
the most studied mode of biofeedback used to alter gait, but still
exhibits a lack of consensus on best practices. Despite the fre-
quency of investigations, the results remain inconsistent specific to
the magnitude and duration of change following visual biofeed-
back, much like the results of our study. The authors suggest that
much of the inconsistency is a result of too few training sessions
and a lack of parameters.25 In the context of our study, perhaps
prolonged exposure to the VID FB is necessary to allow time for
the patients to adapt to the new information. Other future studies
should determine the efficacy of other technologies such as accel-
erometers within socks,26 external focus of attention via laser,27 and
auditory biofeedback that have the potential to improve gait in
patients with CAI.14
Limitations
A major limitation of our study is that we relied on the premise that
the majority of individuals with CAI have increased lateral plantar
pressure during walking. This premise is supported by the multiple
studies that found individuals with CAI do in fact have altered
plantar pressure biomechanics10,12,13,28,29; however, we did not
evaluate our participant population prior to the start of the study.
Since the previously mentioned studies presented group means, in
theory, some individuals with CAI may in fact not have altered
biomechanics during walking, making gait retraining ineffective
for those patients. Another limitation of this study is that we
operated under the assumption that a neutral positioned shoe would
correspond to a neutral COP distribution during walking. None of
our participants had a baseline “neutrally” positioned foot; there-
fore, each participant did attempt to alter their gait pattern during
the VID FB condition. However, it is feasible that if the patient
altered his/her biomechanics via the transverse plane as opposed to
the frontal plane, that either medial or lateral shifts could occur.
Conclusion
Real-time video feedback did not consistently alter plantar pressure
measures in a manner that would be advantageous to patients with
CAI during treadmill walking. Simply providing a cue to promote a
neutrally-positioned foot is an inadequate strategy to improve
biomechanics in patients with CAI. Future studies should focus
on developing other low-cost gait retraining interventions or the
refinement of cues provided during real-time video feedback.
Acknowledgments
This work was supported, in part, by funds provided by the University of
North Carolina at Charlotte.
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Effects of Real-Time Visual Feedback on Gait 233
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