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Effect of custom-made and prefabricated insoles on

plantar loading parameters during running with and
without fatigue
ab ab ab
Angel Gabriel Lucas-Cuevas , Pedro Pérez-Soriano , Salvador Llana-Belloch , Cecili
c ad
Macián-Romero & Daniel Sánchez-Zuriaga
a
GIBD (Grupo de Investigación en Biomecánica Aplicada al Deporte), University of Valencia,
Valencia, Spain
b
Department of Physical Education and Sports, University of Valencia, Valencia, Spain
c
Clínica Podológica, University of Valencia, Valencia, Spain
d
Department of Anatomy and Human Embryology, University of Valencia, Valencia, Spain
Published online: 13 May 2014.

To cite this article: Angel Gabriel Lucas-Cuevas, Pedro Pérez-Soriano, Salvador Llana-Belloch, Cecili Macián-Romero & Daniel
Sánchez-Zuriaga (2014) Effect of custom-made and prefabricated insoles on plantar loading parameters during running with
and without fatigue, Journal of Sports Sciences, 32:18, 1712-1721, DOI: 10.1080/02640414.2014.915422

To link to this article: http://dx.doi.org/10.1080/02640414.2014.915422

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 Journal of Sports Sciences, 2014
Vol. 32, No. 18, 1712–1721, http://dx.doi.org/10.1080/02640414.2014.915422

Effect of custom-made and prefabricated insoles on plantar loading

parameters during running with and without fatigue

ANGEL GABRIEL LUCAS-CUEVAS1,2, PEDRO PÉREZ-SORIANO1,2, SALVADOR

LLANA-BELLOCH1,2, CECILI MACIÁN-ROMERO3 & DANIEL SÁNCHEZ-ZURIAGA1,4
1
GIBD (Grupo de Investigación en Biomecánica Aplicada al Deporte), University of Valencia, Valencia, Spain, 2Department
of Physical Education and Sports, University of Valencia, Valencia, Spain, 3Clínica Podológica, University of Valencia,
Valencia, Spain and 4Department of Anatomy and Human Embryology, University of Valencia, Valencia, Spain
Downloaded by [Florida International University] at 15:53 28 August 2014

(Accepted 12 April 2014)

Abstract
Controversy exists whether custom-made insoles are more effective in reducing plantar loading compared to prefabricated
insoles. Forty recreational athletes ran using custom-made, prefabricated, and the original insoles of their running shoes, at
rest and after a fatigue run. Contact time, stride rate, and plantar loading parameters were measured. Neither the insole
conditions nor the fatigue state modified contact time and stride rate. Addressing prevention of running injuries, post-
fatigue loading values are of great interest. Custom-made insoles reduced the post-fatigue loading under the hallux (92 vs.
130 kPa, P < 0.05), medial midfoot (70 vs. 105 kPa, P < 0.01), and lateral midfoot (62 vs 96 kPa, P < 0.01). Prefabricated
insoles provoked reductions in post-fatigue loading under the toes (120 vs. 175 kPa, P < 0.05), medial midfoot (71 vs.
105 kPa, P < 0.01), and lateral midfoot (68 vs. 96 kPa, P < 0.01). Regarding both study insoles, custom-made insoles
reduced by 31% and 54% plantar loading under the medial and lateral heel compared to the prefabricated insoles. Finally,
fatigue state did not influence plantar loading regardless the insole condition. In long-distance races, even a slight reduction
in plantar loading at each foot strike may suppose a significant decrease in the overall stress experienced by the foot, and
therefore the use of insoles may be an important protective mechanism for plantar overloading.

Keywords: foot orthoses, running, fatigue, gait analysis, injury prevention

Introduction The high prevalence of these injuries may be

because the foot is the first body segment which
Running is a cyclical activity that involves the athlete
interacts with the ground during locomotion
striking the ground about 600 times per kilometre,
(Cubukcu, Alimoglu, Balci, & Beyazova, 2005). As
where the ligaments, tendons, and the musculoske-
a consequence, analysing how the loading is distrib-
letal system have to attenuate from 1.2 to 4.0 times
uted on the plantar surface may be of great interest
the body weight (Lieberman et al., 2010; Ribeiro
in order to better understand the potential detrimen-
et al., 2011; van Gent et al., 2007). Even though
tal effects of overloading (Morag & Cavanagh,
the body is prepared to deal with all those impacts
1999). Running surface (slope, hardness) (Ho
below the injury threshold, the accumulation of the
et al., 2010), footwear (Queen et al., 2010), type of
repetitive loading during a running event may result
foot (Jonely, Brismée, Sizer, & James, 2011), foot
in overuse injury (Lieberman et al., 2010; Withnall,
orthoses (Lee, Lin, & Wang, 2012), abnormal bio-
Eastaugh, & Freemantle, 2006), especially patellofe-
mechanics and the task being performed (Ho et al.,
moral pain syndrome (Swart, van Linschoten,
2010) all influence plantar loading. Moreover, the
Bierma-Zeinstra, & van Middelkoop, 2012; Thijs,
ability of the body to absorb this loading may change
De Clercq, Roosen, & Witvrouw, 2008), stress frac-
as the runner becomes fatigued, hence muscle fati-
tures (Chuckpaiwong, Cook, Pietrobon, & Nunley,
gue has also been suggested to play a major role
2007; Queen, Abbey, Wiegerinck, Yoder, & Nunley,
when addressing overloading of the body structures
2010), plantar fasciitis (Ribeiro et al., 2011), medial
leading to injury occurrence (Clinghan, Arnold,
tibial stress, patellar tendinitis, metatarsalgia, and
Drew, Cochrane, & Abboud, 2008; Withnall et al.,
Achilles tendinitis (Taunton et al., 2002).
2006). In this sense, strategies aiming to reduce

Correspondence: Angel Gabriel Lucas-Cuevas, GIBD, Department of Physical Education and Sports, University of Valencia, C/Gascó Oliag no 3, Valencia,
46010, Spain. E-mail: angel.lucas@uv.es

© 2014 Taylor & Francis


overloading such as foot orthoses may play a major
role in injury prevention when the athlete becomes
fatigued.
The tibialis posterior muscle is believed to play a
key role in providing dynamic support to the foot
during the stance phase of gait (Pohl, Rabbito, &
Ferber, 2010). As a consequence, fatigue of this
muscle as a result of a prolonged run may lead to
imbalances about the ankle and foot, resulting in
changes in plantar loading (Willems, De Ridder, &
Roosen, 2012). Whereas several studies showed
reductions in plantar loading under the rearfoot
(Bisiaux & Moretto, 2008) and metatarsals
(Willson & Kernozek, 1999), other authors have
reported lower plantar loading under the toes
(Nagel, Fernholz, Kibele, & Rosenbaum, 2008).
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Moreover, increased plantar loading under the med-
ial midfoot and all forefoot regions were noted by
Weist, Eils, and Rosenbaum (2004) during an incre-
mental treadmill protocol, but no changes in peak
pressures were observed by Alfuth and Rosenbaum
(2011) after running 10 km. All of the above men-
tioned studies did investigate plantar loading in fati-
gued athletes, however, results are unclear regarding
how plantar loading changes as fatigue appears.
Foot orthoses are in-shoe devices used to ensure
that the static and dynamic functioning of the feet is
as close as possible to the ideal (Werd & Knight,
2010). The use of orthoses has been suggested to
provide plenty of benefits including pain relief,
increased proprioceptive and tactile inputs, improve
comfort (Lee, Shiroma et al., 2012) and they have
specially been identified as one potential tool for
decreasing lower extremity injuries by reducing the
magnitude and rate of loading (Dixon, Waterworth,
Smith, & House, 2003; Lee, Shiroma et al., 2012;
Pérez-Soriano, Llana-Belloch, Martínez-Nova,
Morey-Klapsing, & Encarnación-Martínez, 2011;
Razeghi & Batt, 2000).
Special attention must be paid to the distinction
between “over the counter” or prefabricated insoles
and custom-made insoles. A wide variety of stores
have shelves filled with non-specific orthoses in dif-
ferent shapes and sizes for the customer to buy them
when “needed”. On the other hand, a custom-made
insole is derived from a three-dimensional represen-
tation of the individual’s foot in order to subse-
quently construct a device capable of maintaining
the subtalar and midtarsal joints in the corrected
position during active gait (Werd & Knight, 2010).
Although it would be reasonable to believe that this
kind of orthosis will better fulfil the athlete’s expec-
tations than a shoe insert taken off the shelf chosen
strictly by size of the foot (Bus, Ulbrecht, &
Cavanagh, 2004; Goske, Erdemir, Petre,
Budhabhatti, & Cavanagh, 2006), scientific evidence
to support their effectiveness is needed.
Orthoses effect on running biomechanics 1713
The aim of this study was therefore to examine
whether custom-made insoles provide better loading
distribution than prefabricated insoles and to evalu-
ate the effect of the fatigue state on plantar loading
parameters when running using both alternatives. It
was hypothesised that the use of custom-made
insoles would lead to lower plantar loading com-
pared to the control and prefabricated insoles since
they are specifically adapted to each athlete’s foot.
Our second hypothesis was that athletes would exhi-
bit greater plantar loading after the fatigue protocol
for every insole condition as a consequence of the
muscle fatigue provoked by the run.
Methods
Participants
An a priori analysis of effect size and sample size was
made for a desired power of 95%. Effect size was
estimated by means of Cohen’s f (Cohen, 1998),
calculated from the results of published work which
studied similar dependent variables (plantar pres-
sures, contact times), with fatigue (Bisiaux &
Moretto, 2008) or insole type (Lee, Lin et al.,
2012) as independent variables. Sample size was
calculated using the G*Power 3 software (Faul,
Erdfelder, Lang, & Buchner, 2007). The result was
an estimated minimum sample size of 34 participants.
Forty recreational runners: 21 males and 19 females
(30.35 + 5.21 years; 1.70 + 0.09 m; 64.38 + 10.72 kg)
were recruited via advertisement in running clubs,
running events and University Athletic teams.
Inclusion criteria included no history of lower extre-
mity injuries within the last year, no history of foot
and ankle surgery within the past 3 years, no previous
use of foot orthoses, and running at least 20 km
per week. All participants gave written informed con-
sent before participation. The study procedures
complied with the Declaration of Helsinki and were
approved by the University ethics committee.
Test conditions and insole personalisation
Plantar loading variables were measured under two
different fatigue states: (1) at rest (PRE) and (2)
fatigued (POST) while using three different types
of insoles: (a) original insole of the shoe as control
insoles (CI); (b) prefabricated insole (PI), bought in
a store and chosen only according to the foot size of
the athletes; and (c) custom-made insole (CMI)
built from a three-dimensional representation of the
athlete’s feet.
For the personalisation of the custom-made
insoles, participants stood on a Printlab2 platform
(Podiatech®, Voiron, France) composed by a pair of
silicon vacuum bags that enabled the recreation of
 1714 A. G. Lucas-Cuevas et al.
the plantar print. Based on the foot print, a plaster
mould was created, and through a thermo-welding
process (Podiatech®, Voiron, France) the three-
dimensional insoles personalised to the participant’s
foot were built. Neither the participants nor the
investigators knew about the insole condition being
measured.
Test protocol
Participants performed all tests running on a tread-
mill (Excite Run 700, TechnoGymSpA,
Gambettola, Italy). Since the inclination can alter
the distribution of plantar loading, 0% slope was
adjusted on the treadmill in order not to affect this
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parameter (Alfuth & Rosenbaum, 2011). The
experimental phase of the study was carried out
during 2 weeks (Figure 1). The first day, participants
carried out an incremental submaximal test on a
treadmill to determine the individual running speed
just below their anaerobic threshold. The incremen-
tal test consisted on a warm-up stage of 5 min at
2.78 m/s (10 km · h−1) followed by 3 min stages at
which the treadmill speed increased 0.56 m · s−1
(2 km · h−1). Blood lactate samples from the ear
lobe were taken using Lactate Pro® Analyser (Arkay
Factory Inc., Shiga, Japan) at the end of each stage.
Blood lactate level was used as the main physiologi-
cal variable for determining the individual “fatigue”
speed as it has been previously suggested to be a
useful tool to effectively predict exercise perfor-
mance (McArdle, Katch, & Katch, 2005). On this
basis, the speed of the last stage before reaching
4 mmol of blood lactate concentration was estab-
lished as the individual running speed for each ath-
lete. Following the determination of the individual
fatigue speed, a pair of insoles (custom-made or
prefabricated) was randomly given to each partici-
pant. Randomisation was performed via a computer-
based algorithm programmed within a Microsoft
Excel datasheet. The participants were asked to use
their own footwear with the assigned insoles leading
their daily routine during that week for adaptation
Figure 1. Representation of the study timeline.
purposes. Athletes wore their own running footwear
during the adaptation week and throughout the tests,
as recommended by previous studies which suggest
that athletes wear their own footwear in order to
introduce no further change in their running cus-
tomary condition as would be caused by using a
uniform testing shoe (Nagel et al., 2008; Weist
et al., 2004; Willson & Kernozek, 1999). Tests
were performed 1 week after the insole distribution.
At the running tests, participants warmed up for
7 min at 2.78 m · s−1 (10 km · h−1) (which also
served as familiarisation time on the treadmill
(Paroczai & Kocsis, 2006) with the original insoles
of the shoe (control insoles) or the study insoles
(custom-made or prefabricated) at random.
Subsequently, participants ran for 7 min at
3.33 m · s−1 (12 km · h−1), which is the velocity
most commonly used when analysing plantar loading
during running (Chuckpaiwong, Nunley, Mall, &
Queen, 2008; Dixon et al., 2003) and it has been
appointed to match the 3 h 20 min to 3 h 45 min
marathon time usually reported by recreational run-
ners (Hennig & Milani, 1995). Within the last min-
ute of the run, plantar loading variables were
measured using instrumented insoles (Biofoot
2001®) at 500 Hz during 6 s. Since no significant
differences in plantar loading have been found in
previous studies between both feet, only the left
foot was instrumented for plantar loading analysis
(Weist et al., 2004; Willson & Kernozek, 1999).
After the first measurement, the insoles were
replaced by the second condition (control or study
insoles, depending on the initial order) and the 7-
min run at 3.33 m · s−1 was repeated so that plantar
loading variables could be measured again with the
second pair of insoles. Afterwards, participants per-
formed the fatigue run which consisted on 12 min at
their individual fatigue speed previously determined
in the progressive test (4.04 + 0.36 m · s−1). No
symptom of muscle pain was observed or reported
throughout the run. At the end of the run, once the
athletes were fatigued, plantar loading variables were
measured again during two 1-min runs at 3.33 m ·
s−1: 1 min while running with the control insoles
(post-fatigue control condition) and 1 min with the
study insoles (post-fatigue study condition)
(Figure 2). At the end of the test, participants
received the second pair of study insoles depending
on the initial randomisation (custom-made or pre-
fabricated) and came back to the laboratory after
another adaptation week to repeat the protocol with
the control and the second pair of study insoles.
Plantar loading analysis
Plantar loading variables were recorded with Biofoot
2001® in-shoe pressure measurement system (IBV,
 Orthoses effect on running biomechanics 1715

Figure 2. Representation of the running tests protocol.

Valencia, Spain). This system has been shown to be

reliable (Martínez-Nova, Cuevas-García, Pascual-
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Huerta, & Sánchez-Rodríguez, 2007) and comprises

a pair of instrumented insoles each with 64 piezo-
electric sensors connected to a logger attached to the
waist.
Figure 3 shows the 9 anatomical plantar zones
used for data analysis (Fourchet et al., 2012;
García-Pérez, Pérez-Soriano, Llana, Martínez-
Nova, & Sánchez-Zuriaga, 2013; Pérez-Soriano
et al., 2011): hallux (H), toes (T), medial metatarsal
(MM), central metatarsal (CM), lateral metatarsal
(LM), medial midfoot (MF), lateral midfoot (LF),
medial heel (MH), lateral heel (LH). Contact time
(CT in seconds) and stride rate (SR in steps/minute)
were also analysed. The plantar loading parameters
that were acquired included (Tsung, Zhang, Mak, &
Wong, 2004):

1. Mean peak pressure (Px in kPa): the average

value of the maximum pressures from each step
recorded over the foot region analysed.
2. Pressure–time integral (PTI in kPa · s−1): the
area beneath the pressure–time curve, which
indicates how much pressure is being applied
on that area over that period of time.

All variables were analysed for at least 6 footsteps

during the athlete’s running gait for each insole
(control, prefabricated, custom-made) and fatigue
(PRE, POST) condition.

Statistical analysis
The SPSS.18® statistical package was used for sta-
tistical analyses. After checking the normality of the
variables (Kolmogorov–Smirnov), a descriptive ana-
lysis of the data was performed. The sphericity
assumption was verified by the Mauchly test. Then,
a Two-way Repeated-Measures ANOVA with insole
and fatigue as intra-subject factors and plantar load- Figure 3. Foot sole divided into 9 areas for plantar loading
ing parameters as dependent variables was analysis.
 1716 A. G. Lucas-Cuevas et al.
performed. Effect size was assessed by means of the
partial eta squared (Cohen, 1998). Bonferroni post
hoc was carried out to provide details as to the
whereabouts of significant differences. Significance
was set at α = 0.05.
Results
Effect of the insole condition
In the present study, the different insole conditions
did not affect stride rate and contact time. However,
the use of insoles did affect plantar loading, what is
shown in Figures 4 and 5. Regarding mean peak
pressure, prefabricated insoles showed significant
lower pressures in toes, medial midfoot, and lateral
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midfoot compared to the control insoles both in pre-
and post-fatigue conditions. Similarly, custom-made
insoles also provoked a significant decrease under
the hallux, medial midfoot, and lateral midfoot com-
pared to the control insoles regardless of the fatigue
condition. Furthermore, the custom-made insoles
also decreased mean peak pressure in the medial
heel compared to the prefabricated insoles.
Regarding pressure–time integral, both custom-
made and prefabricated insoles showed lower values
under the lateral midfoot compared to the control
condition. Moreover, regarding comparisons
Figure 4. Pre- and post-fatigue mean peak pressure in the 3 insole conditions.
(Mean values + SD) * P < 0.05; ** P < 0.01.
Figure 5. Pre- and post-fatigue pressure–time integral of the 3 insole conditions.
(Mean values + SD) *P < 0.05; **P < 0.01.
between the two study insoles, the custom-made
insoles significantly decreased pressure–time integral
compared to the prefabricated insoles under the lat-
eral heel. The effect size of the differences indicates
large effects for all the significant differences
observed (Cohen, 1998) (Table I).
Effect of the fatigue
Individual fatigue speed, running time during the
individual fatigue protocol, lactate concentration,
and rate of perceived exertion values are presented
in Table II.
No clear trend showing how fatigue alters contact
time and stride rate was observed. Similarly to the
effect on contact time and stride rate, the fatigue
state did not significantly modify either mean peak
pressure (P > 0.05) or pressure–time integral
(P > 0.05) under any of the areas observed, regard-
less of the insole condition.
Interaction between Insole and fatigue conditions
The effect of the insole conditions on the dependent
variables of the study was not modified by the run-
ner’s fatigue state, since no significant interaction
(P > 0.05) was found between the two factors
 Downloaded by [Florida International University] at 15:53 28 August 2014

Table I. Summary of significant differences (means (95% confidence intervals)) of plantar loading variables for the different insole conditions and fatigue states.

PRE PRE PRE POST POST POST

Effect size
(partial
Control Prefabricated Custom-made Control Prefabricated Custom-made P etasquared)

Px hallux (kPa) 200.62 N.S. 90.06a* 129.80 N.S. 92.41a* 0.037 0.115
(140.87–260.38) (51.94–128.18) (82.79–176.80) (50.77–134.05)
Px toes (kPa) 213.62 131.85a** N.S. 175.44 120.45a** N.S. 0.016 0.249
(161.02–264.98) (84.55–179.16) (123.74–227.13) (75.63–165.27)
Px medial foot (kPa) 107.74 76.48a** 65.20a** 104.80 71.13a** 70.29a** <0.001 0.423
(75.76–139.72) (52.28–100.68) (42.64–87.76) (78.26–131.33) (52.61–89.64) (48.98–91.59)
Px lateral foot (kPa) 99.50 66.66a** 55.86a** 96.30 68.31a** 61.66a** <0.001 0.435
(75.29–123.72) (50.70–82.62) (35.82–75.90) (68.94–123.66) (46.80–89.83) (39.23–84.08)
Px medial heel (kPa) N.S. 189.38 133.58b* N.S. 183.90 122.87b* 0.023 0.229
(141.53–237.23) (91.10–176.05) (141.46–226.34) (79.32–166.42)
Integral 4.59 3.24a** 2.26a** 5.85 3.58a** 2.57a** <0.001 0.415
lateral foot (kPa · s–1) (3.59–5.58) (2.43–4.05) (1.12–3.40) (3.92–7.79) (2.22–4.93) (1.54–3.61)
Integral N.S. 6.42 3.10b** N.S. 5.16 2.29b** 0.004 0.318
lateral heel (kPa · s–1) (3.98–8.87) (1.99–4.21) (3.68–6.64) (1.28–3.30)
a b
Notes: PRE, pre-fatigue; POST, post-fatigue; Px, mean peak pressure; integral, pressure–time integral; N.S., non-significant; differences compared to control insoles; differences compared to
prefabricated insoles; *P < 0.05; **P < 0.01.
Orthoses effect on running biomechanics
1717
 1718 A. G. Lucas-Cuevas et al.
Table II. Individual running speed, lactate concentration, and
RPE values measured during the fatigue protocol (N = 40).
Item Mean ± SD
Individual running speed 14.54 ± 1.29 km · h−1
Running time 9.51 ± 1.29 min
Lactate concentration 3.1 ± 0.2 mmol
RPE 14.0 ± 1.3
Note: RPE, Rating of perceived exertion.
analysed (insoles and fatigue) for any of the depen-
dent variables.
Discussion
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Although it has been observed that the use of insoles
is able to positively distribute plantar loading during
running (Dixon et al., 2003; Lee, Shiroma et al.,
2012; Pérez-Soriano et al., 2011; Razeghi & Batt,
2000), there is a recent controversy involving the
commercial distribution of prefabricated insoles
which are being sold to athletes based solely on
their foot size, hence their effectiveness in preventing
and treating running injuries remains unclear (Goske
et al., 2006; Werd & Knight, 2010).
The values of contact time observed in this study
are very similar to those presented in other studies
(Alfuth & Rosenbaum, 2011) for the same motion
(running) and especially for the same velocity of
study (3.33 m · s−1), since contact time is strongly
affected by speed. In general, greater contact time
will produce a slower running gait and, in the same
way, lower contact time will result in greater running
speed (Chapman et al., 2012; Morin et al., 2012).
Stride rate is directly related to stride length, both
being the main basic parameters that determine run-
ning speed (Mercer, Vance, Hreljac, & Hamill,
2002). Although alterations in stride rate are com-
pensated by modifications in stride length, other
cofactors such as leg length, personal running tech-
nique, and style and the different methodology used
involving equipment, participants, and protocol may
explain stride rate variability among studies
(Hoffman, 1971).
In the present study, neither contact time nor
stride rate was significantly modified by insole inter-
vention. These results can be considered as positive
and valuable findings, since it implies that the use of
orthoses may be able to modify plantar loading with-
out altering the individual stride length and stride
rate. This would allow athletes to undergo preven-
tion and treatment strategies through orthotic use
without suffering any modification in these running
parameters.
Regarding the effect of the fatigue state, no signif-
icant effect was observed in contact time and stride
rate regardless of the insole condition. In general,
contact time is believed to increase when the athlete
is fatigued because higher contact times have been
associated with a decrease in running economy,
which is a typical characteristic of the fatigued con-
dition (Hasegawa, Yamauchi, & Kraemer, 2007;
Nummela et al., 2008). On the other hand, literature
suggests that running under a fatigued condition
provokes modifications on stride rate. Several
authors have found increases in stride rate during
running in a fatigued state (Kyröläinen et al., 2000;
Place, Lepers, Deley, & Millet, 2004). However,
whereas Place et al. (2004) observed these differ-
ences during a 5 h run test at a constant speed on a
treadmill, Kyröläinen et al. (2000) registered these
differences after a marathon race. On the other hand,
other studies have found decreases in stride rate after
a fatigue test consisting of 1 h at the athlete’s indivi-
dual fatigue speed (Hunter & Smith, 2007), after a
45 min run at 85% of the athletes’ peak oxygen
consumption (Dutto & Smith, 2002), and after a
treadmill run to volitional exhaustion at a speed
close to the athletes’ 10 km race pace (Siler &
Martin, 1991). Nevertheless, it is suggested that the
best running performance at any given speed is per-
formed at self-selected stride length, and lengthening
or shortening it will provoke higher aerobic demands
resulting in lower economy and earlier onset of fati-
gue (Hunter & Smith, 2007). As a result of all the
evidence presented, the fatigue of the protocol may
have not been intensive enough and therefore the
athletes may have not reached a condition where
biomechanical changes associated with fatigued run-
ning could be observed.
Regarding the effect of the different insoles, it is
very interesting that custom-made insoles
decreased mean peak pressure under the hallux
by 45% compared to control insoles. Previous stu-
dies have identified that specific populations such
as hallux valgus and hallux rigidus patients or
pronated runners experience elevated values of
pressure under the hallux (Ledoux & Hillstrom,
2002; Martínez-Nova et al., 2010; Zammit,
Menz, Munteanu, & Landorf, 2008). According
to Sánchez-Rodríguez, Martínez-Nova, Escamilla-
Martínez, and Pedrera-Zamorano (2012), this ele-
vated loading may even “represent a pathological
status” and “demonstrate a worse clinical picture”.
For this reason, taking into account that the hallux
is the last part of the foot that contacts the ground
before the flying phase of running and due to its
relevant role during the puss-off phase, relieving
almost half of the loading under this zone by using
custom-made insoles may imply a important ben-
efit for these specific populations during running
(Eils et al., 2004; Martínez-Nova et al., 2010;
Sánchez-Rodríguez et al., 2012).

Pressure–time integral has also been appointed as
a relevant variable to take into account because it
provides information not only about how much load
a specific area of the foot is experiencing during a
task, but for how long the force is being applied
(Mickle, Munro, Lord, Menz, & Steele, 2011).
Burns, Crosbie, Ouvrier, and Hunt (2006) found a
reduction in pressure–time integral in 154 people
with cavus foot using custom-made orthosis while
walking, which was associated with a 74% decrease
in foot pain, whereas another descriptive study
showed that diabetic patients with claw or hammer
toe deformities experienced greater pressure–time
integrals than diabetic patients without deformities,
thereby highlighting the relevance of this parameter
(Mickle et al., 2011). In the present study, a signifi-
Downloaded by [Florida International University] at 15:53 28 August 2014
cant decrease of pressure–time integral in both cus-
tom-made and prefabricated insoles was observed
compared to the original insoles, resulting in 54%
and 35% reduction of pressure–time integral under
the lateral midfoot, respectively. This finding pro-
vides evidence that the use of both of the insoles
analysed in this study (custom-made and prefabri-
cated) were able to modify the plantar load experi-
enced in specific foot areas during running, what is
in accordance with the results observed during walk-
ing (Burns et al., 2006; Mickle et al., 2011).
Moreover, attending to the differences between
both insole conditions, some remarkable observa-
tions should be mentioned. Custom-made insoles
significantly decreased mean peak pressure under
the medial heel by 31% and pressure–time integral
under the lateral heel by 54% compared to the pre-
fabricated insoles. These results show a pressure
pattern indicating that custom-made orthoses pro-
vided better loading attenuation under the rearfoot
compared to the prefabricated insoles, which is the
foot area that firstly contacts the ground in rearfoot
strike runners, who are reported to be the majority of
athletes (Alfuth & Rosenbaum, 2011; Laughton,
Davis, & Hamill, 2003; Lieberman et al., 2010).
Overloading of this area has been associated with
calcaneus spur, plantar heel pain, and plantar fascii-
tis, and being plantar fasciitis a musculoskeletal dis-
order that affects 25% of the athletes (Ribeiro et al.,
2011). Therefore, this reduction of plantar loading
under the rearfoot through the use of custom-made
orthoses could imply a protective mechanism to
reduce the incidence of overuse running injuries.
Several studies have suggested that fatigue pro-
duces a change in the running pattern resulting in a
reduction of heel and toes loading and an increase in
forefoot loading, specifically under the metatarsal
heads (Nagel et al., 2008; Weist et al., 2004). This
reduction in heel and toes loading at the expense of
augmented forefoot loading shows a shift that has
been explained as an increase in local muscle fatigue
Orthoses effect on running biomechanics 1719
of the toe flexors, which results in a reduced stabilis-
ing and control function of the foot leading to over-
load of the metatarsal heads (Nagel et al., 2008;
Weist et al., 2004). These authors suggested that
the lower involvement of the toes during the push-
off phase could be associated with an increased dor-
siflexion in the metatarsophalangeal joints, leading to
higher loading values under the metatarsal heads and
subsequently to an increased overuse running injury
incidence, especially metatarsal stress fractures. In
the current study, a trend indicating a general
decrease albeit not significant in plantar loading
was found with fatigue. These results are in agree-
ment with other studies, where fatigue did not pro-
voke any shift in the plantar loading distribution
during running (Alfuth & Rosenbaum, 2011). The
discrepancy of results between our findings and
those observed in previous studies could be
explained by the huge variability among the meth-
odologies used. Whereas some studies measured
plantar loading during walking before and after a
running event (Bisiaux & Moretto, 2008; Nagel
et al., 2008), other studies used very different events
to provoke fatigue such as a 20-km race (Willems
et al., 2012), a 10-km race (Alfuth & Rosenbaum,
2011), or an incremental run protocol on a treadmill
(Weist et al., 2004; Willson & Kernozek, 1999).
Moreover, most of the studies measured plantar
loading at individual’s self-selected speed (Willems
et al., 2012) or estimated through a percentage of
their individual best running time (Alfuth &
Rosenbaum, 2011), hence plantar loading was mea-
sured at a different running speed for each partici-
pant. Since running speed strongly affects plantar
loading (Fourchet et al., 2012), to the author’s
knowledge this is the first study to measure plantar
loading with custom-made and prefabricated insoles
before and after a fatigue event having all the athletes
running at the same speed during plantar loading
analysis (3.33 m · s−1).
Some limitations have to be considered when
interpreting the results. The use of a treadmill to
better control the variables of the study (running
slope, speed, hardness of the surface) instead of a
natural running environment could lead to different
running biomechanics. During the present study, the
foot strike pattern of the athletes was not taken into
consideration. In future studies, it will be of interest
to measure this variable in order to better under-
stand the effect of foot orthosis on plantar loading.
Also, participants used their own running shoes.
Although inherent characteristics of running shoes
may slightly alter running biomechanics (Ly, Alaoui,
Erlicher, & Baly, 2010), in this study participants ran
using their own running shoes to introduce no
further changes in their customary running condi-
tions (Weist et al., 2004). Finally, due to the fatigue
 1720 A. G. Lucas-Cuevas et al.
protocol carried out in this study, the participants
may not have reached a state fatigued enough to
provoke adaptations in their running biomechanics.
Conclusion
In the current study, both insoles (custom-made and
prefabricated) were able to significantly decrease
plantar loading under different areas (hallux, toes,
midfoot, heel) compared to the original shoe insole
condition. Moreover, plantar loading was not influ-
enced by muscle fatigue, regardless of the insole
condition. The results of this study suggest that the
use of orthoses (either custom-made or prefabri-
cated) may be an important protective mechanism
Downloaded by [Florida International University] at 15:53 28 August 2014
for plantar overloading in healthy athletes running
long-distance races.
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