Foot and Ankle Surgery 1997 3:1-14

Review article
Plantar pressure distribution measurements.
Technical background and clinical applications
D. R O S E N B A U M * A N D H.-P. BECKER~"
*Abteilung UnfallchirurgischeForschung und Biomechanik, Universita't Ulm-Klinikum, Ulm,
Germany, +ChirurgischeAbteilung, Bundeswehrkrankenhause, Ulm, Germany

Summary
Measurement of ground contact forces can be used to assess the
loads to which the human body is subjected in normal activities,
like walking, or in more demanding situations such as in sports.
With regard to clinical problems it is useful to compare the loads in
the limb either between injured and non-injured or pre- and post-
traumatic or -operative states. Otherwise, comparisons between
patients and control groups are necessary. Measurement of the
plantar pressure, i.e. the distribution of force over the sole of the
foot, is useful as it provides detailed information specific to each
region of contact. A wide variety of measurement systems are
available on the market. These systems should be considered with
respect to their technical specifications and the intended application.
In general, one should distinguish between different sensor
principles (resistive, capacitive, piezoelectric) and different devices
(platform, insole, single transducer system). Platform systems are
restricted to use in a laboratory setting (embedded in a walkway)
and are used for barefoot measurements. Insole or single transducer
systems can be used to record the plantar pressures within the shoe
and therefore are appropriate to evaluate the effects of different
shoe constructions or modifications like orthotics. Some of the
precautions to be taken into account for reproducible measurements
and the factors influencing pressure patterns have to be considered.
Furthermore, the application of plantar pressure measurements to
various clinical problems will be discussed.

Keywords: gait analysis; foot loading characteristics; plantar

pressure distribution; instrumentation; sensor characteristics; clinical
applications

Correspondence:Dr Dieter Rosenbaum, Westf. Wilhelms-Universitat

Miinster, Klinik fiir Allgemeine Orthop/idie, Albert-Schweitzer-
Str. 33, D-48129 M~inster, Germany.

© 1997 Blackwell Science Ltd 1

2 D. R O S E N B A U M & H.-P. BECKER
Introduction
Functions of the foot
The foot is the terminal link of the kinematic chain
in human locomotion. During standing the foot
assists in the control of the delicate muscular activity
that is needed to keep balance. The functions of the
foot during walking are two-fold. A passive function,
providing a first stage of cushioning of the impact
forces the human body is subjected to during walking
and running and an active function, transferring the
internal forces produced by the muscles to the ground
in order to accelerate the body during push-off.
Why do we need plantar pressure measurements?
According to Newton's third law action equals
reaction. During walking interactive forces are
transferred between the human body and the ground.
Measurements of these ground contact forces can be
used to assess the external loads to which the human
body is subjected in normal situations like walking
or in more extreme situations such as in sports.
When the loads have to be interpreted in order to
distinguish between normal and abnormal, objective
evaluation tools are necessary as pointed out by
Schwartz & Heath (1932) [1]. With regard to clinical
problems it is useful to assess foot function by
comparing the loads either between the injured and
non-injured limb or between pre- and post-traumatic
or -operative states. Otherwise, comparisons between
patients and control groups are necessary. The
importance of assessing foot mechanics during gait
has also been acknowledged by Katoh et al., [2]:
'Clearly, the foot is critical to an understanding of
the mechanics of gait, as the foot often affects the
normal motion pattern of the entire lower extremity.
Alteration of normal foot mechanics can adversely
influence the normal functions of the ankle, knee,
hip and even the back'.
Due to an increased interest in objective tools for
the evaluation of pressures underneath the foot, the
market for plantar pressure measurement devices
has expanded recently. The aim of this paper is to
provide the potential customer with basic information
to facilitate comparison of different systems, sensors
and devices and to review the clinical applications.
Furthermore, some of the potential problems that a
new user of a pressure distribution measurement
system might encounter and necessary precautions to
avoid them will be mentioned.
Objectives of clinical gait analysis
The basic task of clinical gait analysis is the
description of normal gait patterns in order to
establish a base for further comparisons. This task,
however, is quite complex due to the fact that a wide
variety can be found in a normal, symptom-free
population. It is, therefore, difficult to draw the line
between normal and abnormal. The problem can
sometimes be solved by the definition of a clearly
non-physiological pattern in a patient with an
unequivocal gait disturbance. This 'negative'
definition may help to identify those subjects that
fall in the same category although they exhibit the
problem to a lesser extent. Furthermore, functional
evaluation after different kinds of treatment
(conservative or surgical) or rehabilitation
programmes with the help of gait analysis may be
used to address the issue of quality control that has
gained more importance in recent years. Finally, gait
analysis has proved useful in the design and
development of prosthetic devices and the observer
of the paralympics can assess the progress that has
been made in this area by admiring the performance
of these athletes.
Critical technical specifications of gait analysis
systems have been summarized by Brand [3] who
stated that the system should be accurate and
reproducible, stable over time, not interfere with the
motion to be measured, cost effective and
independent of mood, motivation and pain.
What constitutes critical information for a clinician
that can be gained from gait assessment? Four reasons
that would justify clinical gait analysis have been
given by Brand [3]. First, the results could serve the
purpose of diagnosis, meaning that the results could
help to distinguish between different disorders or
different reasons for the same disorder. Second,
information of this kind might assist in the selection
of different treatment options. Third, valuable
information could be gained if a prognosis of the
outcome of the treatment is possible. Finally, the
information could assist the assessment of the
severity of disease or injury and could therefore
be helpful not only for evaluating patients in one
situation but also longitudinally to follow their
individual development by repeating the gait
analysis.
© 1997BlackwellScienceLtd, Footand AnkleSurgery,3, 1-14

In clinical practice there are different methods of
gait analysis that correspond to a certain degree to
different levels of expenditure. A valuable tool for
first instance analysis is visual observation although
it has to be realized that it is only useful for severe
abnormalities of gait. However, in pathological gait
thirty observations per leg have to be registered
during a period of one second or less so that even
an experienced clinician may be overloaded with
visual cues. This has been shown by Saleh &
Murdoch [4] who compared visual observation and
biomechanical analysis of five amputees walking
with a prosthesis in optimal alignment as well as
intentional misalignment. The authors demonstrated
that visual observation is an unreliable clinical skill
since only 22% of the quantitatively analysed
deviations were correctly identified by the observers,
all experienced clinicians. This judgement has been
supported by Attinger who demonstrated that even
skilled clinical observers were not able to determine
gait asymmetry with certainty [5]. Next, the
description of the gait pattern would involve a
kinematic analysis. Here variables such as step or
stride length and cadence (stride rate per minute)
are obtained with simple measurement tools (stop
watch, tape measure) or with elaborate two- or three-
dimensional motion analysis systems that provide
information about the time course of the translational
and rotational movement of the body segments.
Analysis of the causative factors of movement leads
to kinetic analysis that deals with the measurement
of forces, pressures and moments that are
responsible for the gait pattern. The last level is
electromyographic analysis that deals with the
neuromuscular control of the movement, i.e. the
muscle activity underlying the movement.
Force vs. p r e s s u r e
In kinetic gait analysis the quantities force and
pressure are important variables and therefore have
to be clearly distinguished. It has to be realized that
the quantity 'force' describes the interaction between
two bodies or the body and its environment whereas
'pressure' is the measure that analyses the
distribution of the force across a surface area
(pressure equals force divided by area). The unit of
force is the Newton that is defined as the force
necessary to accelerate a mass of I kg by I m s -2.
© 1997BlackwellScience Ltd, Footand Ankle Surgery, 3, 1-14
P L A N T A R PRESSURE D I S T R I B U T I O N 3
Pressures are reported as force per area unit (N m -2
or Pascal). For diabetic patients it has been realized
that 'Pressure is the critical quantity that determines
the harm done by the force' (P.W. Brand, 1988). This
also holds true in general since force describes the
overall loading effect whereas pressure describes the
potential damaging effects in the tissue. Not only
for diabetics but also for other patients with lower
extremity problems, the measurement of plantar
pressures, i.e. the distribution of the force over the
sole of the foot, is useful. It provides detailed
information specific to each region of the contact area
so that the gait disorder can be attributed to a region
of the foot.
Force m e a s u r e m e n t s
The most commonly used instrumentation for kinetic
information about gait has been force platforms,
Based on three dimensional force transducers in each
of the four corners of the plate, these devices can
measure alI three components of the ground reaction
force (based on the conventions of the widely used
piezoelectric force plate, Kistler Instrumente AG,
Winterthur, Switzerland; please note that other
conventions are also in use).
• Fx=medio-lateral shear force (horizontal force
perpendicular to the movement direction)
• Fy = antero-posterior force (horizontal force in the
movement direction)
• Fz = normal force (perpendicular to the surface of
the platform; vertical force in the direction of the
gravitational force if the platform is mounted in a
level walkway).
Furthermore, the software usually provides
information about the force vector that indicates the
point and direction of force application. Finally, the
free rotational moment applied to the force plate is
calculated. The main advantage of force plates is
their ability to record all directions of the ground
reaction force. Furthermore, due to the high
frequency response platforms can be used with good
accuracy for fast events with high frequency force
signals. However, the disadvantage is that these
systems do not provide insight into the distribution
of the load over the plantar surface and therefore
have limited relevance to the anatomy or pathology
of the foot [6]. Roy pointed out that 'the resultant
4 D. R O S E N B A U M & H.-P. BECKER

force is a useful concept as it reflects the net effect Desirable s e n s o r characteristics

of the ground reaction force on the body as a whole;
The potential user or buyer should realize that the
but a knowledge of the distribution of forces is
sensor characteristics of the pressure measurement
essential in determining what is happening to
device or system should be in accordance with its
individual parts of the foot' [7]. This information
intended use. The faster the movement the more
is provided by pressure distribution measurement
factors like sampling rate and frequency response
systems.
should be considered. Furthermore, the spatial
resolution of a sensor mat becomes more critical with
decreasing size of the structures of interest. Based
Pressure distribution measurements on pressure measurements and further calculations
Davis et al. [11] advised that sensor sizes should
Early investigations of foot pressure patterns have
be below 6.4 by 6.2 mm (medio-lateral and antero-
used the imprint in soft materials such as plaster of
posterior directions) in order not to underestimate
Paris [8] comparable to the foot prints seen in the
actual pressures in the recording of plantar pressure
sand on the beach. These qualitative devices were
patterns. For children's feet, for example, a higher
only able to capture the shape of the foot and
spatial resolution as compared to adults' feet is
the deepest impressions in the surface. The
desirable due to the smaller size of the foot and its
first quantitative measurements using an air filled
skeletal structures. It should be noted that the sensors
chamber were performed by Marey [9] and Carlet
will always measure the average pressure over the
[10] in the last century. The development of arrays
whole sensor surface. Therefore, for small anatomic
of deformable materials that left an ink print or were
structures that produce a defined pressure peak
recorded by optical methods followed. Although
(e.g. the metatarsal heads) larger sensors will
there are still some simple mechanical devices,
underestimate the real pressure values due to the
such as the Harris foot mat, in use, today's
lower pressures around the peak [12].
pressure measurement systems rely on specialized
The pressure range should be sufficiently high to
electromechanical sensors. In essence, the pressure
accommodate the expected peak pressures and total
sensors are force transducers that measure the force
loads. Finally, a high sensitivity and linearity as well
acting on a known surface. Thus they provide the
as a low hysteresis of a single sensor and low crosstalk
necessary information to determine the pressure by
(i.e. unwanted signal transfer from a loaded sensor
dividing force by area. In the 'SI' nomenclature the
to a neighbouring unloaded sensor) between sensors
pressure values should be reported in units of Pascal
is essential in order to ensure accurate and reliable
(Pa) which equals a force of 1 Newton on 1 square
recordings. For a comparison of the sensor
meter (1 N m-2). For foot pressures the values usually
characteristics of the different sensor types the reader
reach the kilopascal (kPa) or megapascal (MPa) range.
may refer to an overview by Nigg [13].
Some of the manufacturers use units like Newton
per square centimeter (1 N cm -2 10 kPa).
=

In general, electromechanical transducers have the Sensor principles

ability to convert a mechanical event into an electrical
signal that can be recorded and stored for further data
analysis (usually on a computer). The transducers
change their electrical properties upon material
deformation. A wide variety of measurement systems
are available. These systems should be considered
with respect to their technical specifications and the
intended application. One should not look for the
'best' system but for the most appropriate system
with respect to the prerequisites of the project. In
general, one should distinguish between different
sensor principles and different devices.
Various sensor materials are in use for force and
pressure measurements. Their working principles
will be explained briefly.
Strain gauge sensors
These sensors change their resistance as a
consequence of the mechanical deformation of a
conductor that is usually glued to a beam that is
exposed to bending. The external load changes the
conductor's length and cross-sectional area that are
directly related to its resistance. These low-cost

© 1997 BlackwellScienceLtd, Footand Ankle Surgery, 3, 1-14


sensors exhibit a good linearity but need a certain
deformation of the loaded beam. They have to be
carefully applied in order to ensure low crosstalk.
The main field of application of this sensor technology
is in force plates (e.g. AMTI force plates, Advanced
Mechanical Technology Incorporated, Watertown,
MA, USA).
Conductive~resistive sensors
These sensors consist of two printed circuits
separated by a conductive layer of carbon or ink (e.g.
FSR=force sensing resistors, Interlink Electronics
Europe, Echternach, Luxembourg). Under load
application the conductive layer connects the two
circuits and increasing pressure gradually lowers the
resistance. Their main advantage is that they are thin
so that they can be worn inside a shoe without
affecting the subject's gait. The sensors have
also been used successfully as foot switches to
discriminate stance and swing phases in the gait
cycle. However, the sensors have been shown to alter
their sensitivity after repeated use and therefore do
not provide highly reliable values [14--16].
Capacitive sensors
Capacitive sensors consist of two electrically
conducting surfaces separated by a compressive
dielectric material, usually a rubber layer. Under an
external load the rubber material is compressed and
the change in the distance as well as the change in
the dielectric constant of the material between the
plates alters the capacitance of the sensor. The
capacitance change can be electronically converted
into a voltage change. The dielectric material should
possess good elastic recoil properties in order to
minimize hysteresis effects. (Hysteresis describes the
difference of an output signal between loading and
unloading for a given input signal. If the compressed
material is slow in regaining its original shape when
being unloaded the force or pressure reading i s higher
than the applied load). Due to deformation these
sensors exhibit a certain nonlinearity and hysteresis
and therefore have a limited frequency range. They
should not be operated with sampling frequencies
above 100 Hz [17] and are therefore not appropriate
for highly dynamic events like sprinting, jumps and
landings. For measurements o f human gait these
sensors are sufficiently fast and perform accurately
and reproducibly. They are used for pressure
© 1997 BlackweU Science Ltd, Foot and Ankle Surgery, 3, 1-14
P L A N T A R PRESSURE D I S T R I B U T I O N 5
distribution plates and insoles (EMED and PEDAR,
Novel GmbH, Munich, Germany).
Piezoelectric sensors
For piezoelectric sensors ceramic materials are used.
The piezoelectric effect is found in non-conducting
materials (e.g. quartz, ceramics, lead zirconate
titanate) and in thin flexible PVDF films
(polyvinylidenefluoride). The electronic dipoles in
the material react under the influence of an external
load with a displacement of charges on a molecular
level generating electrical charges at the sensor
surface. Charge amplifiers can be used to convert
these charges to voltages. These sensors (with the
exception of PVDF) are highly elastic, show little
material deformation and exhibit low hysteresis
effects. Therefore, they are suitable for recording of
high-frequency loading events. On the other hand
PVDF and most piezoceramic materials are
temperature sensitive so that the environmental
conditions should be controlled and kept as
constant as possible. The properties of piezoelectric
transducers and their electronic processing have been
described in more detail elsewhere [18]. They are
used for force plates (Kistler Instrumente AG,
Winterthur, Switzerland) and single sensors (h.a.l.m.
elektronik GmbH, Frankfurt/Main, Germany).
All the above mentioned sensors measure the
normal component of the ground reaction force and
neglect the shear forces. It has been discussed (but
not proven conclusively) whether the additional
measurement of shear forces is necessary since it
might provide additional valuable information, e.g.
for diabetic patients. First attempts to measure shear
stress distribution have been reported but have not
yet been made commercially available.
Sensor configurations
The available sensor technology has been used
in various sensor configurations with different
application areas.
Pressure distribution platform systems
Similar to force platforms, pressure distribution
platform systems can be used for static and dynamic
measurements (i.e. standing and walking) in normal
and pathological subject populations. However, the
platforms are restricted to the use in a laboratory
6 D. R O S E N B A U M & H.-P. BECKER
setting. Usually they are embedded in a walkway
and the subject has to contact the platform after
several steps of approach. Therefore, it is necessary
to provide a 'warm-up' period in order to familiarize
the subject with the situation and to reproducibly
generate a normal walking pattern. During this time
the starting position can be determined so that the
subject makes contact with the platform in a normal
manner of walking without adjusting stride
length. Although the platforms can be used for
measurements in shoes, their usual application lies
in barefoot measurements as the shoe interface can
mask the crucial information about the loading of
the anatomical structures of the foot. Therefore, these
systems are used to evaluate foot function in healthy
or injured populations but not for investigation of
footwear properties or the effects of orthotics.
In-shoe systems
These systems detect the plantar pressures between
the foot and the shoe and can therefore be used to
measure the effect of different shoe constructions
or modifications such as orthotics directly at the
shoe-foot interface. A general advantage of these
systems is that repeated steps can be recorded in one
measurement. Since the orientation of the foot with
respect to the sensor matrix or single sensors remains
the same, multiple steps can be easily averaged and
analysed with the same mask. Some of the available
systems are combined with a portable data logger
that allows field measurements outside the
laboratory. This enables monitoring of loading
situations in work or sports environments that are
more relevant to the cause of overload problems.
Matrix devices
These arrange the sensors in rows and columns and
provide an active sensor area for the whole plantar
surface of the foot.
Sole systems with discrete sensors
These systems have sensitive elements at certain
sites on the sole corresponding to the anatomical
structures in a normal foot. The advantage is a
reduced amount of data that has to be processed and
stored so that faster sampling rates are possible. On
the other hand, critical information may be lost when
high pressure areas are not in contact with one of
the sensors. This can be the case in severe foot
deformities that do not conform with the sensor
arrangement since it is designed to accommodate
normal feet. These limitations may be overcome with
discrete sensors that can be applied under defined
anatomical locations after palpation by the
investigator. This allows for a sensor placement
according to individual foot shape. These systems
usually use small, inexpensive sensors but one has to
be aware of the potential problem that the protruding
sensors may act as a foreign body in the shoe. In
order to prevent discomfort and subsequent changes
in the natural walking pattern the sensors can be
embedded in a customized thin insole of comparable
thickness. In general one has to be aware of the
fact that the total ground reaction force cannot be
determined with discrete sensor systems since large
amounts of this force are lost to measurement in
areas without a sensor underneath. However, it has
been shown that the use of only eight sensors under
the main load bearing structures of the foot are suited
to estimate the ground reaction forces during running
[19].
Some of the commercially available platform and
in-shoe measurement systems are listed in Table 1
(platform) and Table 2 (in-shoe) with a short
description of the most important technical
specifications.
Data processing, analysis and
presentation
Standard parameters
Various parameters that are extracted from the
pressure distribution measurements can be
determined for the whole plantar surface or for
selected foot regions. Figure 1 shows the parameters
in a pressure-time curve for a single pressure sensor.
The value of these parameters is dependent on the
specific aims of the research project. For diabetics,
for example, the peak pressure values and their sites
are of great importance since exceeding a pressure
threshold may lead to occlusion of blood supply
and subsequent tissue break-down with ulceration.
(However, the critical value has yet to be determined).
For other applications the temporal characteristics of
loading of the foot may be of interest in order to
evaluate the neuromuscular control of the ground
contact. Information can be derived from looking at
© 1997 BlackwellScienceLtd, Footand Ankle Surgery,3, 1-14
 P L A N T A R PRESSURE D I S T R I B U T I O N 7

Table 1
Technical specifications of commercially available platform systems for pressure distribution measurements

Size of Local Sampling

active area Number of resolution frequency
Sensor type [cm] sensors [sensors cm -2] [Hz]

EMED1 Capacitive 19 x 30-30 x 50 1500-2736 1-4 50-100

F-Scan2 Resistive 30 x 46 2138 1.4 165
Pedobarograph3 Optoelectronic 36 x 36 not applicable <0.1 25
Musgrave4 FSR 19 x 39 2048 4 56
Buratto5 Semi-Conductor 38 x 41-43 x 143 1900-7632 1.6 150

Novel GmbH, Munich, Germany (based on three different models: SF-1, SF-2 and SF-4).
2Tekscan Inc., Boston MA, USA.
3Information obtained from Hughes et al. [49].
4preston Communications Ltd., Llangollen, UK.
5Zeno Buratto spa, Crocetta, Italy (based on four different models: Compatto, ACP1, ACP2 and ACP3).

Table 2
Technical specifications of commercially available in-shoe pressure distribution measurement systems

Local Sampling
Thickness Number of resolution frequency
Sensor type [mm] sensors [sensors cm2] [Hz]

Matrix devices
Pedar ~ Capacitive 2.6 max. 256 0.7 100
F-Scan2 Resistive 0.2 960 4 165
Buratto Dinatto3 Semi-Conductor 1 64/128 1.6 150
Single sensors
Parotec4 Hydrocells 2.5 16/24 not applicable 100-250
CETIS-PD 16s Piezoceramic 2.0 2x8 not applicable 1000

1Novel GmbH, Munich, Germany.

2Tekscan Inc., Boston MA, USA.
3Zeno Buratto spa, Crocetta, Italy.
4F.W. Kraemer, Remscheid, Germany.
5h.a.l.m, elektronik GmbH, Frankfurt/Main, Germany.

t h e r e l a t i v e c o n t a c t t i m e s in c e r t a i n r e g i o n s a n d slightly subjective. Only a few methods have used

the time of occurrence of the peak pressures. A c o m p u t e r a l g o r i t h m s to a u t o m a t i c a l l y s u b d i v i d e t h e
c o m b i n a t i o n of t i m e a n d a m p l i t u d e f a c t o r s is r e f l e c t e d f o o t p r i n t i n t o a p r e d e t e r m i n e d n u m b e r of r e g i o n s
in t h e i m p u l s e v a l u e s t h a t a r e d e t e r m i n e d f r o m t h e [6]. T h e s e a l g o r i t h m s h a v e l a t e l y b e e n i n c o r p o r a t e d
pressure-time integral or force-time integral. i n t o c o m m e r c i a l l y a v a i l a b l e s o f t w a r e (e.g. N o v e l W i n
V e r s i o n 1996, N o v e l G m b H , M u n i c h , G e r m a n y ) . I n
our own projects we usually distinguish eight regions
Regions of interest of i n t e r e s t ( F i g u r e 2).
The above mentioned parameters can be obtained
for the whole plantar surface or certain anatomically
defined regions of the foot. No general standard
Presentation of pressure patterns
exists for the subdivision of the foot into areas of There are different graphic options for the
interest. Therefore, the decision should depend on v i s u a l i z a t i o n of t h e p r e s s u r e d a t a ( F i g u r e 3). M o s t of
the objectives of the study. the commercial software provides a colour coded
T h e p r o c e d u r e s for s u b d i v i d i n g t h e f o o t h a v e so t w o - d i m e n s i o n a l r e p r e s e n t a t i o n of t h e f o o t p r i n t
far b e e n b a s e d o n i n d i v i d u a l d e c i s i o n s a n d m a y b e and a three-dimensional wire-frame ('pressure

© 1997 Blackwell Science Ltd, Foot and Ankle Surgery, 3, 1-14

8 D. R O S E N B A U M & H.-P. BECKER
Peak
pressure
0..
Onset of Time to Cessation
loading peak pressure of loading
I Duration of loading
lime (ms)
Figure 1
Pressure-time curve (for a single sensor) and parameters of interest
with respect to the amplitude and timing of loading. The time
parameters can also be expressed as a percentage of the whole
contact phase (divide loading duration of a single sensor or area
by the total contact time). The impulse can be obtained by the
summation of the single pressure values multiplied by the time
interval. (Integral of shaded area).
m o u n t a i n s ' ) s h o w i n g either the highest p r e s s u r e
values t h r o u g h o u t the contact p h a s e or single
pictures. A n interpolation of the discrete sensor
values helps to indicate the anatomical structures b y
s u p p o s e d l y increasing the local resolution. Finally,
an isobaric representation d r a w s lines b y connecting
the points of equal p r e s s u r e a n d p r o v i d e s an i m a g e
LH
CH
MH
Figure 2
Foot outline with eight regions of interest that are used in our own projects to evaluate foot loading characteristics. MH=Medial heel,
CH=Central heel, LH =Lateral heel, MF =Midfoot, M1= Medial forefoot (1st Metatarsal), M2/3 = Central forefoot (2nd/3rd Metatarsal),
M5 = Lateral forefoot (5th Metatarsal), H = Hallux.
that is c o m p a r a b l e w i t h the elevation lines in a
topographical m a p .
For statistical results of g r o u p s of subjects a
b a r g r a p h representation on a foot outline is often
u s e d to facilitate u n d e r s t a n d i n g a n d interpretation
of the results.
Anthropometric and kinematic factors
influencing pressure patterns
Various a n t h r o p o m e t r i c a n d kinematic factors have
I
b e e n identified a n d discussed as potential factors
w i t h an i m p a c t on plantar p r e s s u r e patterns. These
factors should be considered for the selection of
subjects w h e n different p o p u l a t i o n s are compared.
Surprisingly, b o d y m a s s does not s e e m to affect
the plantar pressures as m u c h as one w o u l d expect.
For m a l e diabetic patients it w a s d e m o n s t r a t e d that
b o d y m a s s is not a g o o d predictor of plantar pressures
[20]. For n o r m a l subjects a low but still significant
correlation w a s f o u n d only u n d e r the lateral midfoot
a n d third metatarsal h e a d b u t this correlation was
m o r e p r o n o u n c e d in female subjects [21]. For a group
of infants weight-related changes w e r e d e m o n s t r a t e d
b y a correlation b e t w e e n b o d y w e i g h t a n d midfoot
loading [22]; considering the age of the subjects
(between 14 a n d 32 months) these changes can be
attributed to the incomplete d e v e l o p m e n t of the
longitudinal arch.
M5
M2/3
M1
MF
© 1997 Blackwell Science Ltd, Foot and Ankle Surgery, 3, 1-14
 P L A N T A R PRESSURE D I S T R I B U T I O N 9

A. B. C.

Dm
Figure 3
Four different ways to display the plantar pressure pattern: A. 2-D foot print (here shown in grey scale but usually color coded), B.
interpolated image, C. isobaric image, D. wire-frame pressure mountain.

Age related differences Gender related differences

Such differences have been described between
children and adults and have been attributed to softer
foot structures in the developing infantile skeleton
[22]. Duckworth [23] pointed out that the differences
are small probably due to an increase in foot size
and a distribution of the load that helps to keep
the peak pressures within fairly small limits. Minor
differences between adults and an elderly population
can be expected due to a change in gait dynamics.
These have been described by Hennig & Milani [21]
in a study with 49 w o m e n and 62 men. Under the
midfoot region of the male subjects they found
significantly higher pressure values during stance
and gait.
Footshape
The effect of the foot shape has been addressed
already in 1934 by Elftman [24] w h o noted that if

© 1997 BlackwellScience Ltd, Footand Ankle Surgery, 3, 1-14

10 D. R O S E N B A U M & H.-P. BECKER
the second metatarsal is longer than the first it bears
more load and leads to a pressure peak in the centre
of the ball of the foot. Furthermore, different foot
structures like cavus and planus foot types reveal
distinct pressure patterns with higher pressures
under the midfoot of planus feet and under the
central forefoot of cavus feet [25, 26].
Gait velocity
The influence of gait velocity on total force and peak
pressures has been clearly demonstrated [26, 27].
While there is a linear increase when the whole
plantar surface is considered the analysis of areas
of interest has shown that this behaviour can be seen
only in the heel and the medial forefoot areas
whereas the midfoot and the lateral forefoot loading
decrease with speed. Therefore, one cannot use a
correction factor to accommodate for different
speeds but should monitor the subject's kinematic
characteristics.
Shoe construction
Finally, it has been shown that shoe constructions
have an effect on foot loading characteristics. It was
reported that increasing the heel height led to a
deviation of the forefoot loading pattern to the medial
side which was discussed as a possible factor for
overloading the first ray [28]. In a comparative study
on 19 models of running shoes Hennig & Milani [19]
could demonstrate that even shoes with a similar
purpose revealed differences in the in-shoe pressure
distribution.
Factors to control during data collection
In order to assure repeatability of the measurements
some of the above mentioned factors should be
controlled or at least monitored during data
collection. The issue of controlling gait velocity has
been discussed to some extent and remains a matter
of personal choice. A prescribed walking speed will
help to compare the pressure patterns of different
subjects but will most likely prevent the generation
of a natural walking pattern for all subjects. It is
likely to be too fast for some subjects and too slow
for others. Furthermore, the use of a metronome that
has been used to help a subject walk at a certain
stride frequency will force him to concentrate on the
auditory cues and may cause an unnatural stride.
Independent of the decision for or against a freely
chosen walking speed it appears mandatory to record
it and to try to keep it constant between repeated
trials of one subject. This will help to reduce the
intra-subject variability. This goal can be achieved
with light gates at a certain distance or less accurately
with a stop watch.
With respect to the approach the walkway length
should be sufficient to allow enough steps before
reaching the platform so that the gait is normal.
Furthermore, enough space behind the platform will
help to prevent a slowing down of the step during
the measurement. If the first-step method is being
used one should be aware that it is not comparable
with full-gait measurements since the body still has
to be accelerated to the intended walking speed.
However, a first-step procedure is a good method to
measure foot function in a patient population that
has difficulty walking or is not easily able to
target a small pressure distribution platform. High
correlations have been found for first-step against
mid-gait plantar pressure variables [29].
A crucial factor is the 'warm-up' period for the
Subjects. It can regularly be observed that the
invitation to walk normally will often lead to a very
slow and cautious gait pattern that is clearly not
representative of the subject's natural gait. After
several trials in¢reased,gait velocity and step length
can be observed. Once a fairly consistent gait velocity
is achieved the platform will be repeatedly contacted
from a fixed start position. At this point repeated
trials can be recorded and stored. In patients with
severe problems a n d / o r pain, this approach may
lead to early fatigue. In such cases one might have
to accept trials which are not as repeatable as desired.
The selection of patient populations should be
concerned with possible age-related differences.
Therefore, a control group should be taken from the
same population and should be age matched. The
foot shape is usually a factor that is difficult to control.
If a population exhibits an extreme skewness towards
high-arch or flat feet one should keep this in mind
for the discussion of the results.
In spite of all precautions, the variability of human
gait will still be present. In order to obtain a sufficient
level of reliability a certain number of measurements
under controlled conditions will help to minimize
intra-individual variability in an experimental
session. Based on measurement series of 25 repeated
© 1997BlackweUScienceLtd, Footand Ankle Surgery, 3, 1-14

trials with the EMED-F platform Hughes et al. [27]
suggested that 'At least three measurements should
be made for research projects which aim to compare
groups of different subjects' because this resulted in
reliability coefficients above 0.9 for area, force
and peak pressure values. For clinical investigations
this has been confirmed with the Biokinetics
Pedobarograph by Holmes et al. [30] who specified
that the variability in the foot border areas (hallux,
first and fifth metatarsal) is greater than in the central
areas (heel and second metatarsal). Furthermore, it
should be noted that intersubject comparisons are
less reliable than using a subject as his or her own
control [29].
In post-traumatic patients the unaffected limb is
often used for comparison with the injured limb.
This approach assumes the existence of a symmetrical
foot loading in symptom-free subjects. It has been
shown that healthy subjects exhibit a degree of
asymmetry, of up to 5%, in ground reaction force
and contact time parameters and even higher
percentages in regional pressure parameters with a
low mean value (e.g. midfoot loading) [5, 31, 32]. This
has to be taken into consideration when performing
intra-individual comparisons for the evaluation of
functional restoration after trauma treatment. Even
though the asymmetries may increase many times
after injury there is still a tendency to regain
symmetrical loading in order to prevent limping,
Therefore, the so-called unaffected side will often
reveal adaptational changes during the post-
traumatic recovery period so that an additional
comparison with a normal population is advisable
[2].
Clinical applications
The value of pressure d~stribution measurements for
the evaluation of foot pathology or abnormalities
involving the forefoot, midfoot and hind foot has
been widely acknowledged [2] and is reflected in a
variety of papers with clinical applications.
Most studies report on postoperative situations,
whereas only few have proved useful for
preoperative clinical decision making. Evaluating the
results of all the studies raises the critical question
of whether it is possible to distinguish normal from
abnormal. At present, no one has defined clear criteria
for normal gait. Therefore, the interpretation of
© 1997BlackwellScienceLtd, Foot and Ankle Surgery, 3, 1-14
P L A N T A R PRESSURE DISTRIBUTION 11
plantar pressure measurements relies on the intra-
individual comparison or the comparison with larger
groups of non-symptomatic subjects.
Several authors have tried to define normal
walking using force platforms. Herzog et al. [31]
quantified symmetry and asymmetry of normal
human gait for selected variables. They found in a
right-left comparison the upper and lower limits of
normal gait to vary from + 4% to + 13%. Hughes et
al. [33] questioned whether it was possible to use
plantar pressure measurements for diagnostic
purposes due to the wide range of normal values
found in normal subjects. However, they
demonstrated that the equipment was useful to
monitor progress by means of sequential
measurements, to assess the effect of treatment or to
assist in the manufacture of orthotics.
Brand and colleagues attempted in their clubfoot
study a sort of validation of gait results against a
functional rating scale [34]. However, they failed to
demonstrate any correlation of the gait measure
with clinical or radiographical data. Chao et al. [35]
reported a more successful effort using a performance
index based on the gait patterns of patients with
knee disability. A stepwise discriminate analysis
selected and weighted seven gait variables out of a
total of 43 to create their performance index. This
procedure generally discriminated between normal
and abnormal, although not in all cases. Mittlmeier
et al. [36] reported a performance index of five
parameters of dynamic foot contact pressures which
strongly correlated with a clinical rating scale.
Mittlmeier et al. [37] used the plantar pressure
distribution analysis for the quantification of the
severity of gait disturbance in patients with calcaneal
fractures. They also showed in the same study a
change in the joint kinematics in the contralateral
non-injured extremity. Those studies indicate the
attempts of different authors to correlate gait results
with clinical rating scales which were only successful
in a few selected cases.
Other authors investigated the effect of different
surgical approaches on plantar pressure patterns.
Becker et al. [38] compared Evans tenodesis with an
anatomical repair using carbon fibres in patients with
chronic instability. They found a significant increase
of midfoot pressure in the operated foot with Evans
tenodesis and concluded that this reconstruction
flattened the foot by shortening the peroneus brevis
12 D. R O S E N B A U M & H.-P. BECKER
tendon. Rosenbaum et al. [39] studied the long-term
effects of calcaneal fractures on the gait pattern and
found a significant increase of plantar pressure in
the lateral areas of the operated foot. They concluded
from these results that there is a persisting deviation
of gait pattern long after healing. Becker et al. (40)
distinguished good and bad results after operative
treatment of ankle fractures creating forefoot
and hind foot indices. The difficulty with those
studies is to correlate the findings of plantar
pressure measurements with the clinical findings.
Nevertheless, the differences between the operated
and non-operated extremity indicated a severe
disturbance of the kinematic chain in the foot itself.
Several studies exist on the effects of hallux valgus
surgery on plantar pressure. Lanshammer et al. [41]
compared the Keller's operation and distal oblique
osteotomy measuring ground reaction forces at great
toe, first and fifth metatarsal heads. They found
medio-lateral shifts of the centre of pressure after
both operation methods. Similarly, Milani & Retzlaff
[42] reported an incomplete restoration of normal foot
loading characteristics after Keller/Brandes surgery
that manifested in a loading shift from the hallux to
the metatarsal heads. Wanivenhaus & Brettschneider
[43] found a load normalization under the first
metatarsal head after subcapital osteotomy in
patients with hallux valgus. Borton & Stephens [44]
evaluated the effects of basal chevron metatarsal
osteotomy for hallux valgus and reported a
significant reduction of the high pressure areas
(above 490kPa). The measurement of plantar
pressure represents a valuable tool for quality control
in elective orthopedic surgery comparing the
preoperative with the postoperative load patterns.
In our institution the EMED SF2 system has been
used for the evaluation of foot function after trauma
or after conservative or surgical treatment of foot
injuries and deformities. The platform is embedded
in a 7 x I m walkway and the subjects are asked to
walk across the platform at a self-selected speed. Five
trials are recorded from the left and right foot. The
pressure patterns are analysed in eight foot areas
and the parameters from the five trials are averaged
for each subject. The system has been used to
investigate a variety of foot and ankle related
problems.
• Conservative and surgical treatment of lateral
ankle instability [38, 45, 46]
• Hallux valgus surgery with the Mitchell technique
• Malleolar fractures [40]
• Calcaneal fractures [39]
• Metatarsal fractures [47]
• Biomechanical in-vitro investigations [48]
These and other related publications have
contributed to a better understanding of how the
foot works. A wide range of normal features exists
and therefore it is difficult to decide whether the
alteration of pressure patterns is really due to
pathological causes. This may be one of the reasons
why pedobarography is not yet used as a daily
clinical routine.
In conclusion, however, we would agree with Janet
Hughes [33] that there are three areas of clinical use
for plantar pressure measurements
• The assessment of treatment by pre- and
postoperative comparisons.
• The longitudinal evaluation of single patients in
order to control the healing process after an injury
or the progress of a foot pathology.
• The control of effectiveness of orthotic
interventions by in-shoe measurements.
With technical developments and increasing
knowledge of foot function it will be possible to
analyse and interpret the complex information gained
from plantar pressure measurements. It will then
be more likely that valuable information for the
practising clinician will help to discriminate good
from bad results. Already it can be used as a tool to
aid clinical decision making but will never supplant
good careful clinical examination and experience.
Acknowledgements
We would like to express our sincere gratitude to
Professor Ewald Hennig from the Biomechanics
Laboratory of the University of Essen for his thorough
review of the manuscript and valuable suggestions.
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