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DIAB-3762; No of Pages 7

Diabetes Research and Clinical Practice xxx (2006) xxx–xxx

www.elsevier.com/locate/diabres

Daily-life activities and in-shoe forefoot plantar pressure

in patients with diabetes
Nick A. Guldemond a,*, Pieter Leffers b, Antal P. Sanders c, Nicolaas C. Schaper d,
Fred Nieman e, Geert H.I.M. Walenkamp a
a
Department Orthopaedic Surgery, University Hospital Maastricht, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
b
Department of Epidemiology, Fac. Medicine, Maastricht University, The Netherlands
c
Department Rehabilitation Medicine, University Hospital Maastricht, The Netherlands
d
Department Internal Medicine, University Hospital Maastricht, The Netherlands
e
Department Clinical Epidemiology and Medical Technology Assessment, University Hospital Maastricht, The Netherlands
Received 21 April 2006; accepted 17 November 2006

Abstract
Objective: To assess differences regarding in-shoe forefoot plantar pressure (PP) in patients with diabetes during various daily-life
activities.
Research design and methods: In-shoe PP was measured in 93 patients during: level walking, ramp and stair walking, turning in
different settings and while performing the Up & Go test. Separate PPs were determined for the big toe and metatarsal (mt) regions
one to five.
Results: Across all activities, similar PPs were measured in the big toe and mt-1 to mt-3 region. Lower PPs were measured in mt-4
and mt-5 region. PPs during level walking were mostly higher when compared to the other activities ( p  .030). Turning while level
walking resulted in higher PPs than turning while performing the other activities ( p  .033). Higher PPs were measured for both
ramp and stair ascending when compared to descending ( p  .001). In the big toe region, stair descending resulted in higher PPs
than ascending ( p  .001). Across all activities, patients with neuropathy had lower PPs (overall mean 28 kPa) than patients without
neuropathy.
Conclusions: Level walking resulted in the highest forefoot PPs during daily-life activities. Patients with neuropathy had lower PPs
than patients without neuropathy.
# 2006 Elsevier Ireland Ltd. All rights reserved.

Keywords: Daily activities; Diabetic foot; Plantar pressure; Screening

1. Introduction regarding the biomechanics of the diabetic foot has been

Since the introduction of electronic equipment for
plantar pressure measurement, the majority of research
* Corresponding author. Tel.: +31 43 3875031;
fax: +31 43 3874893.
E-mail addresses: ngu@orthop.unimaas.nl, ngu@sort.azm.nl
(N.A. Guldemond).
performed with pressure sensitive platforms and has
been focused mainly on plantar bare foot loading. The
application of pressure sensitive platforms is limited to
laboratory settings and most platforms allow only one
step per run for recording. At the beginning of the
1990s, commercial equipment for in-shoe pressure
measurement became available and is now commonly
used in research as well as in clinical settings. In-shoe

0168-8227/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.diabres.2006.11.006

Please cite this article in press as: N.A. Guldemond et al., Daily-life activities and in-shoe forefoot plantar pressure in patients
with diabetes, Diab. Res. Clin. Pract. (2006), doi:10.1016/j.diabres.2006.11.006
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plantar pressure measurement provides the opportunity
for collecting multiple steps per run.
In-shoe plantar pressure is usually measured during
walking straight on level ground. In previous reports, it
was questioned whether such plantar pressures were
representative for plantar pressures during activities of
daily living [1–3]. Until now, only a few studies have
evaluated in-shoe plantar pressures under more real life
circumstances [2–6]. Only one of these studies was
performed in patients with diabetes and peripheral
neuropathy. Several results of these small sample size
studies were conflicting, e.g. one found that plantar
pressures were lower during turning than straight level
walking [2], while others found the opposite [3,5]. The
primary objective of the present study was to determine
differences between various activities regarding fore-
foot in-shoe plantar pressures in diabetic patients. The
secondary objective was to evaluate whether there were
differences for these activities as far patients with and
without peripheral neuropathy were concerned. We
compared straight level walking with turning, with the
Up & Go test and with ramp and stair walking.
2. Materials and methods
surgery of the foot and/or severe deformity. The latter included
pes cavus, i.e. an excessively elevated foot arch, hallux valgus
more than 158 and severe toe deformity. The degree of hallux
valgus was measured according to the guidelines of the
American Academy of Orthopaedic Surgeons [7]. The pre-
sence of claw toe, mallet toe, curly toe or hammer toe
deformity, was scored according to the definitions of Myerson
and Shereff [8]. The degree of toe deformity was arbitrarily
defined as less (minor), the same (significant) or more (severe)
than the definitions described by Myerson and Shereff,
whereas ‘normal toe’ was recorded if there was no malalign-
ment present. In addition, the medial arch height was sub-
jectively classified as: no arch; lowered arch; normal arch;
elevated arch and excessively elevated arch. Before the start of
the study, patients were informed about all study procedures
and their possible risks. The Research Ethical Committee of
the University Hospital Maastricht approved the study.
Ninety-three eligible patients were screened for peripheral
neuropathy through determination of the vibration perception
thresholds (VPT) at the apex of the hallux with a biothesi-
ometer (Biomedical, Newbury OH) [9–11]. AVPT higher than
25 V was used as the diagnostic criterion for peripheral
neuropathy: 25 V = PNP , >25 V = PNP+. Table 1 con-
tains descriptive data with respect to gender, age, body mass
index (BMI), duration of diabetes, VPT, HBa1c and walking
speed.

2.1. Patients 2.2. Procedures

Diabetic patients were selected from the medical outpa-
tient clinic of the University Hospital Maastricht. Inclusion
criteria were diabetes mellitus type 1 (longer than 10 years
after date of diagnosis) or type 2 (at least 1 year after date of
diagnosis); age between 30 and 75 years and able to perform
daily-life activities without supporting devices. Exclusion
criteria were a history of rheumatoid arthritis, foot trauma
The following timed activities were evaluated: level walk-
ing, the Up & Go test, ascending and descending a ramp and a
flight of stairs (Table 2). Level walking: patients walked two
lengths of 10 m (turn excluded) indoors on a concrete floor in
one single run. Ascending and descending a ramp: patients
ascended and descended a 15% grade ramp of 4 m and turned
on a platform of 62 cm length by 81 cm width. This was a

Table 1
Patient characteristics
PNP PNP+
n 49 44
Gender (female/male) 30/19 29/15
Type of DM (1/2) 18/31 9/35

Female Male Female Male

Mean S.D. Min–max Mean S.D. Min–max Mean S.D. Min–max Mean S.D. Min–max
Age (years) 56.3 9.06 34–69 50.9 9.52 32–70 64.9 8.79 49–75 58.8 10.42 34–72
Duration diabetes 13.8 10.16 3–39 11.6 7.70 1–32 18.1 11.35 2–40 16.3 11.39 3–45
(years)
HBa1c (%) 8.31 1.51 5.9–10.7 8.15 1.08 5.1–9.7 8.25 1.29 6.3–11.8 8.16 1.25 5.7–12.0
Body mass index 28.9 5.17 19.8–39.6 28.2 4.83 20.1–38.0 31.2 7.37 20.0–45.7 29.6 6.44 19.8–45.3
(kg/m2)
VPT 12.3 4.06 5.2–20.5 13.9 5.18 5.7–23.3 41.9 9.79 24.8–50.0 41.3 11.84 14.5–50.0
Walking speed (m/s) 1.04 0.11 0.91–1.28 1.08 0.16 0.71–1.50 0.85 0.13 0.67–1.09 1.05 0.20 0.60–1.38
PNP+, peripheral polyneuropathy; PNP , no peripheral polyneuropathy; DM, diabetes mellitus; VPT, vibration perception threshold; HbA1c,
hemoglobin A1c.

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with diabetes, Diab. Res. Clin. Pract. (2006), doi:10.1016/j.diabres.2006.11.006
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Table 2
Information about activities, number of steps used for analysis and groups of comparison for statistical testing
Activity Trials per patient Distance per trial Turns clockwise Turns counter-clockwise Average number of steps
per patient used for analysis
Straight on performance Turns
Level walking 4 2 m  10 m 2 2 40 8
Up & Go test 2 2m3m 1 1 8 4
Ramp ascending 2 2m4m 1 1 6 4
Ramp descending 2 2m4m 1 1 6
Stair ascending 2 2m3m 1 1 14 4
Stair descending 2 2m3m 1 1 14

Groups of comparison
Level walking vs. other activities L vs. U L vs. RA L vs. SA L vs. LT
Turning while level walking vs. turning during other activities LT vs. UT LT vs. RT LT vs. ST UT vs. RT UT vs. ST RT vs. ST
Ascending vs. descending RA vs. RD SA vs. SD
L, level walking; U, Up & Go test; RA, ramp ascending; RD, ramp descending; SA, stair ascending; SD, stair descending; LT, turning while level
walking; UT, turning while performing Up & Go test; RT, turning while ramp walking; ST, turning while stair walking.

typical a situation in which a subject would turn at a low speed [13]) They were used in order to minimize the influence of
with a small perimeter. Upstairs and downstairs walking: ‘cushioning’ on plantar pressure loading and without any
patients were asked to ascend and descend 10 stairs in their specific adaptation they are not necessarily appropriate for
usual manner (step height 18 cm; board depth 27 cm; 33 grade diabetic feet. This type of shoe is close to what is commonly
inclination). Unilateral use of a handrail was obligatory and worn in the Dutch elderly population. The shoe fitting was
they turned on the landing of the stairwell. For the aforemen- checked according the guidelines described by Shor [14].
tioned activities patients were instructed to walk and turn at a Time was measured to the nearest 1/10 of a second using a
safe and comfortable pace. Timed Up & Go test: patients were stopwatch with interval memory storage.
asked to rise from a standard chair (seat height 45 cm), walk to
and turn around a pylon, which was placed 3 m from the chair, 2.3. Data processing
and return to a sitting position in the chair [12]. Patients were
instructed to ‘‘perform the activity as quickly as you can Pedar Expert1 software (Novel, Munich Germany) was
without overexerting yourself’’. This was a typical test situa- used to select steps from the raw data files. The assignment of
tion in which a subject would accelerate and decelerate at a steps to walking or turning was made by using the recording
relatively high speed in combination with a turn around a time in the data files and the stopwatch intervals. The evalua-
small perimeter. tion was focused on six forefoot regions: big toe and meta-
During all activities plantar peak pressures were measured tarsal one (mt-1) to five (mt-5). The mask for these ‘regions of
with a frequency of 50 Hz per sensor with the Pedar Insole-
system1 (Novel, Munich Germany). The Pedar insoles con-
sisted of a matrix of 99 sensors with an average individual
sensor effective area of approximately 1.5 cm2 and were
placed in both shoes between the socks and shoes. For patient
measurement, the insoles were calibrated to absolute values
using the Trublu1 calibration device (Novel, Munich Ger-
many). A ‘relative or zero calibration’ was performed imme-
diately before each trial by unloading each insole. The Pedar
processing unit was worn in a waist pocket. Plantar pressure
data were recorded with a computer through a 15 m umbilical
cable which was guided during the measurements. All patients
performed the activities in a randomized order in standard
socks and shoes of various widths and neutral fore-/rear foot
Fig. 1. Peak pressures during daily-life activities. L, level walking; U,
height (males: Van Lier: outer sole hardness, i.e. shore type A: Up & Go test; RA, ramp ascending; RD, ramp descending; SA, stair
68, No 814 Loon op Zand, Netherlands and females: Durea ascending; SD, stair descending; LT, turning while level walking; UT,
Greenway: outer sole shore type A: 63, No 6548 Drunen turning while performing Up & Go test; RT, turning while ramp
Netherlands). These shoes are oxford style shoes with a walking; ST, turning while stair walking; mt, metatarsal; kPa, kilo-
relatively stiff innersole material (Shore A higher than 60 Pascal.

Please cite this article in press as: N.A. Guldemond et al., Daily-life activities and in-shoe forefoot plantar pressure in patients
with diabetes, Diab. Res. Clin. Pract. (2006), doi:10.1016/j.diabres.2006.11.006
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4 N.A. Guldemond et al. / Diabetes Research and Clinical Practice xxx (2006) xxx–xxx

L, level walking; U, Up & Go test; RA, ramp ascending; RD, ramp descending; SA, stair ascending; SD, stair descending; LT, turning while level walking; UT, turning while performing Up & Go test;
Min–max
interest’ was designed using Novel ‘create any mask1’ soft-

47–239
50–211
32–269
42–252
42–295
47–285
48–275
45–298
28–228
27–243
ware and verified by individual anterior-posterior radiographs
of the foot [15]. Peak pressure was estimated by calculating
the mean over the total number of steps per activity collected
Metatarsal 5
S.E.

from various trials Table 2. The mean speed during level

4.2
3.7
4.4
5.0
5.5
4.9
4.7
4.4
4.4
4.2
walking was based on the time required to traverse 10 m; per
patient an average of eight measurements was used: 2  10 m
134
118
130
119
144
126
134
127
108
113
M

lengths (turn excluded) per trial with a total of four trials.

Min–max

2.4. Statistical analysis

53–393
60–337
68–428
56–334
34–422
62–337
54–343
53–345
54–293
59–272
At first plantar pressure data of all activities were inves-
tigated for normal distribution by the Kolmogorov–Smirnov
test. Repeated measures ANOVA design was used for ana-
Metatarsal 4
S.E.
7.6
6.1
7.4
5.9
8.7
6.2
6.9
6.4
4.6
4.7

lysis with one between- and two within-factors: The

between-factor was defined as ‘neuropathy’ with two cate-
187
157
179
147
174
153
174
161
127
133

gories (patients with and without neuropathy). The within-

M

factors were defined as ‘activity’ with 10 categories (all

RT, turning while ramp walking; ST, turning while stair walking; M, mean; S.E., standard error; Min, minimum; Max, maximum.

aforementioned activities) and ‘side’ with 2 categories (left

Min–max
110–674
64–511
79–652
76–418
76–579
70–426
92–492
77–513
59–348
70–353

and right foot). For each factor, overall F-ratio tests were
corrected for sphericity violations in the variance–covar-
iance matrix by using the Greenhouse–Geisser degrees of
freedom making the tests more conservative. Mauchly’s test
10.4

10.4
8.1

7.8
9.6
7.9
8.9
8.1
6.8
6.2
Metatarsal 3
SE

of sphericity was used to decide whether this correction was

necessary. Specific category differences were investigated
264
214
253
196
234
215
235
213
159
164

using reversed Helmert contrasts. The following compari-

M

sons were made: level walking versus the Up & Go test, ramp
ascending, stair ascending and turning while level walking.
Min-Max
127–599
71–456
98–576
81–423
94–512
58–417
93–454
60–435
50–348
70–363

Also, we wanted to know whether various styles of turning

would result in different forefoot pressures. Finally, we were
interested in the differences in peak pressure between
ascending and descending for both ramp and stair walking
10.0
9.8
7.7

7.9
9.1
7.5
8.5
7.9
5.9
5.7
Metatarsal 2
S.E.

(Table 2). All comparisons in the analysis were performed

with the peak pressure calculated for the six forefoot regions.
Statistical analysis was carried out with SPSS 12.011 soft-
275
223
268
209
250
225
244
227
161
171
M

ware (SPSS Inc.). An alpha level of 0.05 was chosen to judge

statistical significance.
Min–max
61–615
48–495
68–602
21–539
81–463
43–524
66–536
45–550
29–518
39–483

3. Results

Because the conceptual and statistical problems

Metatarsal 1
S.E.
8.7
7.4
9.8
9.1
8.0
8.2
8.4
8.6
6.9
7.0

associated with analysing both feet of one subject,

Peak pressures during daily-life activities (kPa)

repeated measures ANOVA, with side as within factor,

248
213
251
202
227
226
229
217
165
178

was used for statistical testing. In the overall F-ratio test

M

this analysis showed no statistically significant differ-

ence in peak pressure between left and right foot.
Min–max
88–481
73–445
86–532
60–482

57–500
92–459
74–418
41–338
59–343
8–513

Therefore, the values for each region over both left and
right feet were averaged. The peak pressures for all
activities per forefoot region are presented in Fig. 1 and
10.4
8.9
7.5
9.6
8.5

9.9
7.9
8.3
6.2
6.8
S.E.

Table 3.
For most activities the mt-2 region had the highest
Big toe

peak pressure. However, for all activities peak pressures

249
208
241
217
156
187
225
216
168
168
M

measured in the mt-1 to mt-3 and the big toe regions

Table 3

were fairly similar. The only deviation from this pattern

RA
RD

UT
SA
SD

RT
ST
LT

is that the peak pressure for the big toe was lower during
U
L

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stair walking. Across all activities, lower peak pressures
were measured in mt-4 and mt-5 region compared to the
other regions.
In most forefoot regions, peak pressure during level
walking was higher compared to the other activities
( p  .030). Only for the mt-1 and the mt-5 region,
differences in peak pressure between level walking and
turning while level walking, and between level walking
and ramp ascending were not statistically significant.
For all forefoot plantar regions, turning while level
walking resulted in higher peak pressures, than turning
while performing the Up & Go test, ramp walking and
stair walking ( p  .033). Also, turning while perform-
ing the Up & Go test resulted in higher peak pressure,
compared to turning while ramp and stair walking
( p  .001).
A higher peak pressure was measured for both ramp
and stair ascending in most forefoot regions when
compared to ramp and stair descending ( p  .001). For
the mt-1 regions the difference was not statistically
significant. In the big toe region, stair descending
resulted in a higher peak pressure than ascending
( p  .001).
Across all activities, patients with neuropathy had
lower peak pressures than patients without neuropathy.
Repeated measures ANOVA showed that the overall
effect was 28 kPa (difference of sample means) with a
standard error of the difference of 19.4 (F (1,91) 6.78,
p = .011). The ranking of the activities from the highest
to lowest peak pressure, as shown in Fig. 1, was the
same for patients with and without neuropathy.
4. Discussion
We studied in-shoe forefoot plantar pressure
during simulated daily-life activities in diabetic
patients. The highest peak pressures for all activities
were measured in the mt-1 to mt-3 regions. In these
regions, level walking and ramp ascending resulted in
the highest peak pressure. Peak pressures were lower
in patients with neuropathy than in patients without
neuropathy.
Our finding that level walking and ascending a ramp
resulted in the highest forefoot peak pressure compared
to the other activities contradicts previous studies that
report that activities like turning, ramp and stair walking
result in higher peak pressure than straight level
walking [3,5] and are similar to those of Maluf et al. [2].
Rozema et al. found that the plantar pressures during
rising from and sitting down on a chair were much lower
than during level walking [3]. These measurements
were performed from and to a ‘static standing position’.
Please cite this article in press as: N.A. Guldemond et al., Daily-life activities and in-shoe forefoot plantar pressure in patients
with diabetes, Diab. Res. Clin. Pract. (2006), doi:10.1016/j.diabres.2006.11.006
5
We expected that a more real-life approach of the
transfer from walking to sitting and vice versa would
lead to higher peak pressures. Although patients in our
study were encouraged to perform the Up & Go test as
quickly as possible, this test did not lead to higher
plantar pressures when compared to level walking. We
averaged peak pressures during sitting down and rising
from a chair, consequently no comparisons between
these activities were made.
As reported in other studies, stair walking resulted in
lower plantar pressures than did level walking [2,3]. The
peak pressure in the big toe region was surprisingly low
compared to level walking and ramp ascending.
Contrary to other forefoot regions the big toe was
more loaded during stair descending than stair
ascending.
Our study shows that turning resulted in lower peak
pressures, which supports the results of Maluf et al. [2].
Rozema et al. reported that plantar pressure was higher
during turning when compared to straight level walking
[3]. In this study turning was performed while ‘‘walking
between two concentric circles’’ at a constant speed of
1.6 m/s, which is a much faster then the straight level
walking speed of our patients. Our impression is that
patients mostly slow down before turning and then turn
at a lower speed. Such anticipative turning related gait
was also found in a recent study with elderly subjects
[16]. Additionally, peak pressures further decreased
during turning while ramp and stair walking where a
slower speed was required than during level walking.
Even when we tried to provoke high plantar pressures
with swift ‘pivot’ turning as in the Up & Go test, peak
pressures were lower than level walking. Unfortunately
we have no adequate data on walking speed during this
test. We made no differentiation between in and outside
feet for the analysis of turning activities. Consequently,
small differences for in and outside foot peak pressure,
as have been found in previous studies [2,3], were
possibly averaged out. Also, from a real-life perspec-
tive, it is not to be expected that daily cumulative plantar
stress becomes asymmetrical through turning, since it is
unlikely that people will consistently turn in one
direction.
Patients with neuropathy showed slightly lower peak
pressures (about 10%) during all activities than patients
without neuropathy. The relatively large standard errors
indicate that the spread of peak pressures in both groups
is very large.
It is commonly thought that patients with neuropathy
experience higher plantar pressures during daily-life
activities than diabetic patients without neuropathy
[17,18]. This idea is based on results from bare foot
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plantar pressure studies, which showed that patients
with neuropathy have higher plantar pressure than
patients without neuropathy or healthy controls [19–
26]. Our study shows that in-shoe plantar pressure
during daily life activities is lower in neuropathic
patients. The present analysis was not focused on the
causal mechanism for the explanation of the difference
in plantar pressure between patients with and without
neuropathy. The slower walking speed of patients with
neuropathy probably explains at least part of the
difference in peak pressure, while also adaptive gait
style may play a role. We studied diabetic patients
without severe deformities, limited joint mobility and
gait abnormalities. Some of the results might well be
different in patients with these complications of
diabetes. Further studies in such patient groups are
warranted.
The present study is an added piece in the puzzle of
how foot ulcers develop. In general, daily plantar foot
loading has four determinants: (1) footwear, (2)
performed activity, (3) number of loading cycles and
(4) the temporal pattern of activities.
It is obvious that activity patterns between indivi-
duals vary a lot. Armstrong et al. [27] showed that intra-
individual activity fluctuates; periods of inactivity are
punctuated by relatively sudden pulses of activity over a
short time frame. From the study of Maluf et al. [2] and
our own study it appears that straight level walking for a
longer period of time seems to be less favourable
activity than ‘moving around the house’. Because of the
large variation in used personal footwear and plantar
loading characteristics, inter-individual differences
must be considered in estimating risk for ulceration
in an ‘every day’ perspective.
5. Conclusions
Level walking and ascending a ramp resulted in the
highest forefoot peak pressure compared to other
simulated daily-life activities such as ramp descending,
stair walking, rising from and sitting down on a chair.
Compared to descending, ascending a ramp or stairs
resulted in higher peak pressures. An exception is the
big toe region which had a lower pressure during stair
ascending. Across all activities and plantar regions,
peak pressures were lower for patients with neuropathy
than patients without neuropathy.
Acknowledgement
This study was supported by the Dutch Diabetes
Research Foundation.
Please cite this article in press as: N.A. Guldemond et al., Daily-life activities and in-shoe forefoot plantar pressure in patients
with diabetes, Diab. Res. Clin. Pract. (2006), doi:10.1016/j.diabres.2006.11.006
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Please cite this article in press as: N.A. Guldemond et al., Daily-life activities and in-shoe forefoot plantar pressure in patients
with diabetes, Diab. Res. Clin. Pract. (2006), doi:10.1016/j.diabres.2006.11.006