S84 Oral Presentations / Gait & Posture 24S (2006) S7–S97
[3] Chang CH, et al. J Pediatric Orthop 2002;22:813–8.
[4] Bowen TR, et al. J Pediatric Orthop 1998;18:789–93.
[5] Jameson GG. Dev Med Child Neurol 2004;99:34.
Fig. 2. Foot angle means and standard deviations.
the medial area of the midfoot region for 28.7% of stance. The
COPP then moves from the midfoot into the forefoot region
where it progresses medially and forward passing just lat-
eral to the hallux. The period of time the COPP spends in the
forefoot is 47.5% of stance phase. The results for the compar-
ative analysis of the two methods of long axis determination
are shown in Fig. 2. The A-T method used 3D kinematic
data to determine the long axis of the foot. This method is
consistent with common gait analysis approaches for mea-
suring foot progression angle. The remaining eight bars in
the graph show the long axis angle for the two repetitions
of manual long axis selection by each analyst. Three ana-
lysts were within one degree of the A-T method, while the
fourth analyst, B, was approximately two degrees less than
the A-T method. Statistical analysis found significant differ-
ences between the methods, but no differences between the
analysts. Excellent intra-rater, 0.975, and inter-rater, 0.969,
reliability was observed.
The A-T method employs 3D kinematics to determine the
long axis of the foot. The subjective method was performed
by four observers (G, L, J, and B), two times for each trial.
5. Discussion
The statistical differences shown reflect absolute differ-
ences less than 2◦ , these differences may offer little clinical
relevance. With the data stratified into the medial to lateral
areas of the heel, midfoot, and forefoot clinical classifica-
tions can be generated, i.e. varus, valgus, severe varus, severe
valgus, equinus, calcaneous, and normal. These results give
reasonable confidence that manually selecting the long axis
is an acceptable method for feet that are normally shaped.
However, using the subjective method for malalligned feet
or feet in equinus or varus may not reflect the same level of
confidence. This technique provides a rational basis for an
objective clinical classification of dynamic foot deformities.
References
[1] Stokes IAF, et al. Acta Orthop Scand 1975;46:839–47.
[2] Duckworth T, et al. J Bone Joint Surg 1985;67:79–85.
doi:10.1016/j.gaitpost.2006.11.059
O-52
Biomechanical optimization of orthopedic footwear for
diabetic patients using in-shoe plantar pressure measure-
ment
Sicco Bus a,b,∗ , Rob Haspels b , Carine van Schie a , Paul
Mooren a
a Department of Rehabilitation, Academic Medical Center, University of
Amsterdam, Amsterdam, The Netherlands
b Diabetic Foot Unit, Department of Surgery, Twenteborg Hospital, Almelo,
The Netherlands
1. Summary/conclusions
Using in-shoe plantar pressure assessments to evaluate
orthopedic footwear can be an effective method to achieve
significant pressure reduction at high-risk areas in the dia-
betic neuropathic foot.
2. Introduction
Orthopedic footwear is commonly prescribed to diabetic
patients with prior plantar foot ulceration. Several studies
have reported large inter-individual differences in the pres-
sure reducing effect of various types of custom insoles and
shoes [1,2]. Therefore, predicting the pressure reducing effect
of footwear remains difficult. As a result, it has been argued
that custom footwear should be evaluated and optimized
using in-shoe plantar pressure measurement [1,3]. The pur-
pose of this study was to assess the feasibility of using in-
shoe plantar pressure measurements to optimize the pressure
reducing effect of custom footwear in patients with diabetes.
3. Statement of clinical significance
Diabetic patients with a prior plantar foot ulcer frequently
show recurrence of an ulcer. Although there is limited evi-
dence on the effectiveness of orthopedic footwear in prevent-
ing recurrence of plantar ulceration, optimizing the pressure-
reducing effects of orthopedic footwear using in-shoe pres-
sure analysis may significantly lower the risk for ulcer recur-
rence in these patients.
4. Methods
Ten diabetic patients with peripheral sensory neuropa-
thy and history of plantar foot ulceration who were previ-
 Oral Presentations / Gait & Posture 24S (2006) S7–S97
Fig. 1. Peak pressure diagrams showing the result of footwear modifications made in two cases: a PP reduction from 469 to 319 kPa (= 32%) at the hallux in
one patient (left two planes) and from 239 to 172 kPa (= 28%) at the lateral forefoot in another patient (right two planes).
ously prescribed with orthopedic footwear participated in this
study. Using the Pedar-X system (Novel, Germany), in-shoe
plantar pressures were measured during four walking trials
at a self-selected walking speed. Based on the peak pressure
diagrams and values shown on-screen directly after collect-
ing data, a region(s) of interest (ROI) for optimization (i.e.
pressure reduction) was defined. This was the region with the
highest measured peak pressure and/or with prior ulceration.
A maximum of three rounds of footwear modifications were
applied. After each round the effect of the modifications on in-
shoe plantar pressure was assessed using the same protocol
and a standardized walking speed. Footwear modifications
included all possible shoe or insole adaptations of which the
shoe technician thought they would reduce pressure at the
ROI. Criteria for successful optimization were a 25% or more
reduction in peak pressure or an absolute reduction of peak
pressure below 200 kPa [4]. A detailed analysis of plantar
pressure was performed using Novel Multimask software.
5. Results
A total of 13 ROIs were defined in the 10 patients tested.
The number of optimization rounds varied between one and
three. Mean peak pressure at the ROI was reduced from
344 kPa (S.D. 99) in the non-optimized footwear to 229 kPa
(S.D. 73) after footwear optimization. Twelve out of 13 ROIs
were successfully optimized by a minimum 25% reduction in
peak pressure (mean 33%, range 22–50%, see Fig. 1 for two
examples). In the remaining case peak pressure was reduced
below 200 kPa. The maximum time needed for footwear opti-
mization (including pressure measurement) was 75 min.
6. Discussion
The results showed that the footwear evaluated in this
study could be successfully optimized within three rounds of
S85
footwear modifications and within a reasonable time frame.
These findings suggest that using in-shoe plantar pressure
assessments to evaluate orthopedic footwear can be an effec-
tive method to achieve significant pressure reduction at high-
risk areas in diabetic neuropathic patients. This method pro-
vides the clinical team with a more objective approach to
footwear prescription and evaluation for the diabetic foot.
Whether this approach can contribute to a reduction in plantar
ulcer recurrence in these patients remains to be investigated.
References
[1] Bus SA, Ulbrecht JS, Cavanagh PR. Pressure relief and load redistribu-
tion by custom-made insoles in diabetic patients with neuropathy and
foot deformity. Clin Biomech 2004;19:629–38.
[2] Guldemond NA, Leffers P, Schaper NC, Sanders AP, Nieman FH,
Walenkamp GH. Comparison of foot orthoses made by podiatrists,
pedorthists and orthotists regarding plantar pressure reduction in The
Netherlands. BMC Musculoskelet Disord 2005;6:61.
[3] Cavanagh PR. Therapeutic footwear for people with diabetes. Diabetes
Metab Res Rev 2004;20(Suppl. 1):S51–5.
[4] Cavanagh PR, Ulbrecht JS, Apelqvist J, Stenstrom A, Kalpen A, Bus
SA. In-shoe plantar pressure threshold for the prevention of plantar ulcer
recurrence. Diabetes 2002;51:A255.
doi:10.1016/j.gaitpost.2006.11.060