0198-0211/90/1103-0152$03.
00/0
FOOT& ANKLE
Copyright 0 1990 by the American Orthopaedic Foot and Ankle Society. Inc
The Assessment of Dynamic Foot-to-Ground Contact Forces and Plantar
Pressure Distribution: A Review of the Evolution of Current
Techniques and Clinical Applications
Ian J. Alexander, M.D.*, Edmund Y. S. Chao, Ph.D.t, and Kenneth A. Johnson, M.D.
ABSTRACT
The objective documentation of foot function before and
after therapeutic intervention will be greatly enhanced by
the utilization of devices capable of measuring dynamic
foot pressure distribution. Efforts to develop this technol-
ogy date back to the late 19th century, but only with recent
advances in computers has it been possible to produce
quantitatively accurate high resolution foot pressure dis-
tribution with high sampling rates and easily interpreted
graphic displays. Over the years, a variety of methods
have been employed to study foot pressure. Many of these
techniques have already improved our understanding of
the foot and its function, and have had an impact on the
way we practice. Effective clinical utilization of these new
investigative tools depends on an understanding of their
scientific basis, capabilities and limitations.
INTRODUCTION
Objective documentation is the foundation of the
scientific evaluation of the treatment of disorders of the
musculoskeletalsystem. Historically, the results of ther-
apeutic intervention have been evaluated by physical
examination supplemented by radiographic analysis. In
some instances, inaccuracy and poor reproducibility of
data obtained from physical examination and observer
variation in the assessment of radiographs generates
skepticism as to the validity of published results. Im-
proved objective documentation of dynamic limb func-
tion has been the goal of many investigators. Current
advances in gait analysis are a tribute to the efforts of
these individuals. An objective means of evaluating
disorders of the foot and the effectiveness of methods
* From the Crystal Clinic, Akron, Ohio. To whom correspondence
should be addressed at Orthopedic Surgeons, Inc., 3975 Embassy
Parkway, Akron, Ohio 44333.
t From the Department of Orthopaedic Biomechanics, the Mayo
*
Clinic, Rochester, Minnesota.
From the Department of Orthopaedic Surgery, the Mayo Clinic,
Scottsdale, Arizona.
152
Akron, Ohio, Rochester, Minnesota, and Scottsdale, Arizona
of treating these disorders is an important step in the
overall improvement of foot care. Devices capable of
measuring pressure under the foot are one way to
obtain this objective data. These devices, which have
their origin in the earliest gait analysis systems, have
evolved considerably since their conception. Current
systems are capable of providing a record of both foot-
to-ground contact force and plantar pressure distribu-
tion as a function of time. Graphic data display has
facilitated interpretation of this information by the clini-
cian. Clinical applications have ranged from the docu-
mentation of areas at risk of ulceration in patients with
neuropathic feet, to the objective comparison of results
of surgical intervention for specific foot disorders.
The first studies of dynamic foot-to-ground contact
date back to the work of M a ~ e and y~~Carlet” of Paris
during the last quarter of the 19th century. They used
specially made shoes with air chambers in the soles to
record foot contact to the ground during gait. Carlet’s
pneumatic apparatus consisted of circular walkway 20
m in circumference with a central recording instrument
attached to the subject’s shoes by long rubber hoses.”
Marey modified this device to make the recording in-
strument portable and in doing so used one chamber
instead of two in the sole of the shoe designed by
Carlet.36
Since then a number of techniques of monitoring
dynamic plantar pressure have been developed and
used, including instrumented shoes, in-shoe pressure
transducers, force plates, floor mounted transducer
matrices, and glass plates using the critical light reflec-
tion technique. Each of these has had a place in the
gradual evolution of plantar pressure assessment over
the last 50 years, and a number of systems are currently
becoming commercially available. Their clinical use,
however, is still in its infancy.
The purpose of the first section of this paper is to
outline the development and explain the principles of
operation of the devices in each category mentioned
Foot & Ankle/Vol. 1 1, No. 3/December 1990
above and to point out some of the advantages and
disadvantages of each system. In the second section,
clinical applications of these instruments are reviewed.
Devices for the assessment of static pressure distri-
bution are well covered in a review by Lord34and will
not be discussed.
PART I: TECHNIQUES OF DYNAMIC PLANTAR
PRESSURE ASSESSMENT
The Instrumented Shoe
The first measurements of dynamic foot pressure
using an instrumented shoe were by Carlet” and
mare^,^^ whose techniques were described previously.
Other early work in this field extended the concepts of
these authors. In their early work, Schwartz and Heath
modified the air sole design to enclose pressure-meas-
uring air chambers under the heel, the fifth metatarsal
head, and the great toe.45Subjects wearing the special
shoes walked on an aluminum treadmill and contact of
an exposed wire under each air chamber with the
walkway indicated the point of contact on the recording
device. Graphic display of individual chamber pressures
was printed on a kymograph, an early equivalent of the
strip recorder. The quality of the recordings was excel-
lent, but the pressure data was not quantified.
In the last 20 years, further attempts have been made
to use transducers, and load cells mounted in or on the
soles of shoes. Spolek and Lippert used a strain
gauged, end-mounted, cross-shaped, spring element
under the forefoot and heel of each shoe to measure
vertical reaction and shear A unique feature
of this instrument was its capacity to measure axial
torque. An interesting finding reported by these authors
was that torque developed when walking subjects
changed direction was approximately 30% of the break-
ing strength of the human tibia. The greatest drawback
of this device was its marked prominence under the
shoe, although an “observable” alteration in gait due to
the device was denied by the authors.
A less cumbersome device capable of measuring
vertical force was designed by Miyazaki and I ~ a k u r a . ~ ’
It consisted of a strain gauge mounted on a metal plate
attached to the sole of a shoe. Drawbacks of this
instrumented shoe included variable transducer sensi-
tivity with different foot shapes and shoe rigidity, and
marked subject awareness of the device, led to the
development of another transducer by Miyazaki with
another coworker, Ishida, 6 years later.39Although this
new device, which used two large capacitance trans-
ducers per shoe, was a considerable improvement over
the previous attempt, its capacity to measure only total
vertical force limited its usefulness.
CONTACT FORCES AND PRESSURE DISTRIBUTION 153
The most recent description of an instrumented shoe
was the 1986 report of ran^.^^ He measured ground
reaction forces by embedding multiple 8-mm thick triax-
ial load cells in the sole of the subject’s shoe. Multiple
sequential steps could be studied and center of pres-
sure excursion was documented. The extensive shoe
modification needed to install the transducers made
clinical use of this technique somewhat impractical.
Pad-Like Multifield Pressure Sensitive Transducers (In-
shoe Transducers)
An array of small, disc-like transducers applied to the
sole of the foot is another method of recording dynamic
foot pressure. If thin enough, these transducers can be
accommodated within the patient’s shoes. The two
major subtypes of these transducers are the capaci-
tance transducers and conductive transducers. The
disc-like capacitance transducers consist of two metal
plates separated by a deformable medium. As pressure
is applied to these transducers, metal layer separation
decreases, changing electrical capacitance of the de-
vice and thus the recorded voltage output (Fig. 1). The
design and mechanics of the conductive transducers
are quite different. In the conductive transducers, de-
formation of a portion of the transducer results in a
change in the resistance to current flow through the
transducer. This change in current is registered as a
change in voltage output and can be related to force
applied through calibration. With either the capacitance
or conductive transducer, if force applied and voltage
output are not linearly related, the output can usually
be electrically modified to produce a linear relationship.
Transducers based on other principles have also been
described and they will be outlined as well. In general,
if quantitative data is required, the small transducers
require calibration before each use, as permanent de-
formation of the load sensitive portion of the transducer
after multiple uses will alter its response to the applied
force.
A
A
A-metal foil
t
B-compressible dielectric (foam-like material)
Fig. 1. In-shoe mini-transducers: capacitance type transducer.
154 ALEXANDER ET AL.
Schwartz and Heath were pioneers in the use of
small disc-like pressure sensitive pads to measure foot
contact pressures.46Their calibrated transducers were
taped to the plantar aspect of the foot and measure-
ments were made with the subject barefoot and wear-
ing shoes. Pressure as a function of time was recorded
by a relatively complicated mechanical oscillograph
which used light from prisms reflected by galvanometer
mirrors, electrically linked to the transducers, to expose
a moving 2 0 0 4 roll of photographic paper. Six trans-
ducers on each foot generated pressure readings in
pounds. Although these pioneers claimed high accuracy
and minimal same subject study to study variation, the
device was abandoned-apparently due to “technical
difficulties.”
The next generation of transducer, used extensively
by Bauman and Brand,’ was a 1-mm thick capacitor
with a 1 cm’ pressure sensitive a ~ e a .Nonlinearity
~.~ of
the transducer was accommodated by a preamplifier
which converted changes in capacitance to changes in
voltage. Each transducer was calibrated using a hy-
draulically distended rubber diaphragm with precision
strain gauges. Transducers placed on the plantar as-
pect of the great toe, the first, second, and fifth meta-
tarsal heads, and the heel were held in place with
adhesive tape. The transducers were connected to a
small junction box worn by the patient to which a
preamplifier was joined by a 4.5-m cable. A graphic
display of pressure versus time was produced. The
device was used by the authors in India to study
patients with neurotrophic foot problems.
Most of the contemporary transducers are of the
conductive type. Shereff et al.,49devised a transducer
consisting of two rigid brass plates separated by a
central core of carbon impregnated conductive polyure-
thane foam.49Pressure applied to this transducer com-
presses the conductive foam with a resulting change in
resistance to current flow. Varying the density of the
surrounding nonconductive foam allowed construction
of transducers with different compliances. The authors
felt that the major shortcoming of their transducer was
its ability to measure only vertical force and its misin-
terpretation of horizontally directed forces.
Two groups of investigators have used a cantilever
beam and a wheatstone bridge resistor in the construc-
tion of their transducers (Fig. 2). The first was Lereim
and Serck-Hanssen in 1973.33Their transducer con-
sisted of a membrane on a mounting ring which, when
deflected by applied pressure, produced bending in a
silicone beam. The deflected beam altered resistance
in the transducer producing a measurable deviation in
current proportional to the mechanical displacement of
the beam. The thickness of the device (2.5-mm) made
it necessary to mount the transducer in a PVC insole
Foot & Ankle/Vol. 11, No. S/Decernber 1990
of similar thickness. The positions of the transducers in
the insole were selected by matching a weight-bearing
x-ray of the feet to the precut insoles and marking out
the anticipated high load areas. Holes were punched
out in these regions to accommodate the transducers.
Although the authors suggested that this technique
could possibly be applicable to runners, no clinical
studies using this transducer have been published.
A lower profile conductive transducer was developed
by Soames, et al.’’ This transducer, which is 0.9-mm
thick and 13-mm square, is made of beryllium copper.
The pressure sensitive area is a 3 mm by 5 mm strain
gauged cantilever beam which, when loaded, deflects
into a 0.4-mm recess milled into the underside of the
transducer. (Fig. 2) To obtain accurate readings, the
soft tissues must be sufficiently compliant to distort the
beam, and the transducer must rest on a relatively rigid
surface to avoid obstruction of the recess on the un-
dersurface. A rigid undersurface also assures even
loading of the transducer. Calibration curves produced
by hydraulically distending a rubber membrane over the
transducer showed a linear relationship between ap-
plied force and voltage output. The small outer dimen-
sions of the device allows application of up to 15
transducers per foot, and with a thickness of less than
1 mm, they were easily accommodated within shoe
wear. Potential variation in the positioning of trans-
ducers is one of the major criticisms of this technique.
However, Soames et al.,” state that although it is time
consuming, accurate placement of the transducers was
possible and this was confirmed by consistent results
in repeat, time separated, evaluations of the same
patients. The excellent clinical use of this transducer by
Soames is reviewed in the applications section of this
publication.
Frost and C ~ S Sof* Australia
~ attempted to use hori-
zontally oriented strain gauges to measure vertical
force. In a fashion similar to Lereim and Serck-Hanssen,
they implanted their transducers into a rubber insole.
Their horizontal strain gauge was covered with a rubber
slug glued to both sides so that the thickness of the
transducer matched that of the insole. As a vertical
force was applied to the transducer, flattening of the
rubber produced horizontal tensile forces and a Poisson
strain which was recorded by the strain gauge. A
number of problems, however, developed with this
device. Using this device in a shoe created a bending
deformation of the load cell which, superimposed on
the Poisson strain, created difficulties in data interpre-
tation. Problems with the materials also occurred. Fine
wires leading to and from the transducers had a tend-
ency to break upon insertion of the foot into the shoe
containing the special insole. As well, the rubber used
Foot & Ankle/Vol. 1 1, No. S/December 1990
In-shoe mini-transducers
conductive type
Examples:
Rl
R2
From Lereim and Serck-Hanssen: From Soames et al:
Bull Pros Res, 1973 Med Biol Eng Comput, 1982
in the transducer was a nonlinear material that exhibited
considerable hysteresis and creep.
A completely different type of in-shoe transducer was
described by Hennacy and Gunther.26The pressure
sensitive component of their transducer is a piezoelec-
tric crystal. After shielding the negative side of the
crystal and connecting a center wire to the positive side
of the crystal, it is embedded in epoxy and sanded flat.
Static and dynamic calibration showed a linear trans-
ducer reaction to force applied. The transducer, the
dimensions of which are not provided, is held to the
foot with a spray adhesive and tape. To our knowledge,
no series of clinical patients has been studied using this
transducer.
The measurement of plantar shear forces has been
the focus of Pollard et al.42They developed an inge-
nious “shear transducer” which consists of two metal
discs separated by a layer of silicone rubber. A semi-
conductor field coil is mounted in one slotted stainless
steel disc and the other disc has a small magnet
mounted on a ridge which matches the slot containing
the field coil (Fig. 3). The two discs are assembled with
an intervening layer of silicone rubber, which limits
excursion and maintains a resting position. Translation
of the semiconductor field coil in the magnetic field is
limited to one plane by the matching slot and ridge of
the transducer discs. Relative displacement of the two
discs produces a measurable change in coil resistance
which is proportional to the applied force. Changing the
orientation of the transducer allows measurement of
shear in multiple directions parallel to the transducer
surface. This device has been clinically used to evaluate
CONTACT FORCES AND PRESSURE DISTRIBUTION 155
Fig. 2. Conductive type trans-
ducers. Bottom left from Lereim and
Serck-Han~sen.3~ Bottom right from
Soames et al?’ By permission of
strain gauge International Federation for Medical
and Biological Engineering.
C D
A= semi-conductor field coil C = metal disc with groove
6=small magnet D = metal disc with ridge
Pollard et al: J Biomed Eng. 1983
Fig. 3. In-shoe shear transducer. From Pollard et al.42By permission
of Butterworth and Co. (Publishers).
the effects of different types of shoe wear and forms
of immobilization on plantar shear and the results of
this work will be reviewed later in this paper.
Floor Mounted Devices: An Historical Perspective
The first floor mounted device was described by
Elftman in 1934.22He developed an instrument con-
sisting of a black rubber mat, with pyramidal projections
on its undersurface, resting on a thick glass plate. A
16-mm motion picture camera was mounted beneath
the glass plate to record the effects of the foot deform-
ing the rubber mat. The black mat did not provide
sufficient visual contrast, and to enhance visualization
of the flattened black pyramids a white fluid was intro-
duced into the space between the mat and the glass.
Slow motion viewing of the stance phase film allowed
observation of the change in distribution of pressure
156 ALEXANDER ET AL.
during an ordinary step. Using this device, high pressure
areas appeared darker on the film. A method of quan-
tifying this technique was not developed. The basic
principles of this device are used in some foil-covered
glass plates currently available commercially.
In 1954 Barnett described his plastic pedobaro-
g r a ~ h .It~consisted
.~ of 640 vertically mounted x 3/e
x 6 in beams. The rods were mounted on firm sponge
rubber and, according to the author, each individual rod
could be calibrated by applying a known pressure, and
then measuring displacement of the rod, a task the
investigator did not undertake. All the rods in one row
were marked 3/~ in offset from the mark on the rods in
the adjacent row so that a staircase effect was pro-
duced across the rods from one side to the other.
Illuminated from one side and filmed from the other,
weight-bearing areas were characterized by depression
of a portion of the transverse line. The visual record of
the displacement was accentuated by coloring in the
interval between the depressed line and its original
location. Although labor intensive and not quantifiable,
this technique is the forerunner of today’s floor-
mounted transducer matrices.
Advancing technology and computerization in the last
25 years have led to the use of increasingly sophisti-
cated force plates, the development of the critical light
reflection technique, and the refinement of transducer
matrices.
Force Plate Analysis of Dynamic Foot-to-Ground Contact
Forces
Improvements in force plates have allowed not only
the assessment of reaction force versus time but also
the orientation of applied force in a coordinate plane.
The location of the instantaneous center of applied
pressure can also be determined. To allow sequential
plotting of the center pressure on the outline of the
weight-bearing foot, foot placement has been deter-
mined by film or video recording through a transparent
force plate, or by a chalk or ink imprint on an overlay
covering a standard force plate. In 1975, Grundy et
al.25described filming the progression of weight-bearing
using a glass force plate. This device allowed determi-
nation of center of pressure under the foot and the
simultaneous ground reaction on each selected frame.
With the aid of a computer, velocity of center of pres-
sure and the correlation of center of pressure and
reaction force was possible. A synchronizing clock was
used to match the center of pressure and the film image
of the foot.
A similar set up was used by Katoh et a ~ , who ~’
were, in addition, able to measure fore-aft and medial-
lateral shear forces. These authors also described the
term “foot floor impulse,” arrived at by multiplying
Foot & Ankle/Vol. 1 1, No. 3/December 1990
ground reaction force by the time of force application,
a parameter possibly of greater clinical value than peak
pressures.
The well-known studies of runners by Cavanagh and
L a f o r t ~ n e were
’~ performed using a technique similar
to those mentioned above. They used a Kistler force
platform and determined foot placement by the use of
a chalk imprint. Their work will be discussed in the
clinical review.
Draganich et at.’’ constructed an array of switches,
mounted on a triaxial force plate and covered with a
silicone mat, to electronically indicate the area of foot
contact. This device does not appear to have been
used extensively in a clinical setting.
Floor Mounted Transducer Matrices
To bring the evolution of force plate measurement
one step further, the devices described subsequently
were designed to measure force under specified areas
of the foot in an attempt to identify high pressure areas
and to quantify the local load.
Hutton and Drabble3’ presented an apparatus in
1972 which employed 12 1.4-cm wide by 25-cm long
beams, each of which was suspended from two load
cells with four strain gauges oriented to measure lon-
gitudinal tension. The relatively small 25 x 17 cm load-
sensitive area could be mounted in the walkway with
the beams oriented either transversely or parallel to the
direction of the walkway. Foot position on the instru-
mented area was determined by an imprint of the foot
on paper produced by an ink-covered, plastic-coated
fabric stretched over the beams. The authors described
this technique of assessing the foot placement as being
“fairly close” to accurate. The small size of the load-
sensitive area made it impossible to accommodate the
entire foot in a single test, necessitating at least four
passes to build a composite load-distribution map of
the entire foot. Since foot position on the beams varied
on each test, considerable smoothing of the force ver-
sus position curve occurred with formation of the com-
posite graph. This further compromised the already
limited resolution provided by the 1.4-cm wide beams.
The potential sources of error in the measurements
with this device were multiple.
A similar device, using transparent beams, designed
by Manley and was first reported on in
1979.’* Their force platform consisted of a series of 16
2 X 26 cm transparent beams, with each end mounted
on a strain gauged cantilever. Images of the foot cross-
ing the force plate were generated by two video cam-
eras, one beneath the plate and a second placed above
the plate giving a lateral view of the foot moving across
the plate. Each frame of the computer generated com-
posite showed a histogram of the force applied to each
Foot & Ankle/Vol. 1 1, No. 3/December 1990
transparent beam, a plantar view of the weight-bearing
portion of the foot with a bright spot at the center of
pressure in each load bearing beam, and a simultane-
ous lateral view of the planted foot. Approximately 35
video frames were collected for each stance phase.
In 1975, in an attempt to improve resolution, Arcan
and Brul12 described the use of optical interference
patterns to assess plantar pressure distribution in the
standing individual. Cavanagh and AeI3 described the
dynamic utilization of the optical interference technique
in 1979. The device of Cavanagh and Ae consisted of
a grid of cylindrical elements 11 mm in diameter which
rested upon a photoelastic material. As pressure was
applied to the individual “transducer element,” an inter-
ference ring formed on the photoelastic material under
the transducers. The diameter of this ring is related to
the pressure applied but not in a linear manner. Quan-
titative pressure applied can be derived from a calibra-
tion curve for each individual transducer element. High
speed films of the interference patterns were obtained
and individual frames were manually digitized. A refer-
ence grid with the outline of the shoe to allow plotting
of the vertical forces was obtained by laying impreg-
nated paper sheets over the matrix. Problems with this
system, clearly identified by the authors, included the
large size of the individual transducer element surface,
which reduces resolution and leads to errors in the
calculation of pressure at the boundaries of the foot or
shoe due to incomplete coverage of the individualtrans-
ducer surface, attenuation of peak pressures by 15%
under dynamic loading conditions, substantial lag in the
return of image output to zero, and the tremendous
amount of labor involved in data reduction. Due to these
drawbacks, it appears that this technique has been
abandoned by these authors. A different method of
using photoelastic material has been recently intro-
duced by Rhodes et al.44and this will be discussed in
a later section.
In 1981, Hutton and Dhanendran,” described an-
other floor mounted transducer matrix. This consisted
of a 25 cm x 15 cm array of 1.5 x 1.5 cm load cells.
Each load cell consisted of a 25 mm diameter stainless
steel ring with four attached strain gauges. The output
was amplified and fed into a minicomputer which col-
lected and processed the data. Foot position on the
load sensitive area was again assessed by the fabric-
ink-paper technique described previously. Four record-
ings were made for each foot. Eight predetermined
plantar areas were studied. It is assumed that pressure
versus time for each of these reference areas is deter-
mined by averaging the pressures from each of the four
passes. Quantitative data for reaction forces in each of
these specified areas are generated, but no mention is
made of possible sources of error in these measure-
CONTACT FORCES AND PRESSURE DISTRIBUTION 157
ments. With the transducer surface area exceeding the
size of some of the study areas (i.e., the second toe),
as well as considerable area overlap on individualtrans-
ducers, and variation in peak pressures occurring with
each pass, some degree of inaccuracy seems inevita-
ble. The problem of underestimating foot border pres-
sures due to incomplete coverage of the transducers,
mentioned by Cavanagh and AeI3 in their work, would
be an even greater problem with this device, where
individual transducer surface area is even larger. In
addition, the small size of the load sensitive platform,
25 cm x 12.5 cm, is a limiting factor in studying patients
with large feet.
In the same category, but very different from the
other transducer matrices described, are the portable
capacitance mats described first by Hennig and Ni-
COI.~‘~~’ These consisted of an upper layer of conductive
plates joined in rows, and a lower layer of conductive
plates joined in columns separated by an elastic rubber
material referred to as a “compressible dielectricum.”
Each condenser element of the original mat measured
2.1 x 2.3 cm and total mat size was 20 x 40 cm. As
pressure was applied to each individual transducer, its
capacity increased and resistance to alternating current
decreased. The transducers were hooked up to light-
emitting-diodes (LEDs) and used a “calibration column”
to assess brightness of the LEDs which was related to
applied force in a linear manner. The authors acknowl-
edged the limitations of their technique, including poor
resolution due to transducer size, poor correlation be-
tween foot outline and transducer location, a limited
measuring rate of 25 Hz, and limited precision com-
pared to conventional force transducers. The major
advantages of this technique were its low cost (a major
factor in consideration of office use) and its portability.
Over the past 10 years the capacitance mats and
individual sensors originally described by Hennig and
N i ~ h o I ~ ’ have
, ~ ’ been modified extensively by research
sponsored by the German Ministry of Technology. The
current device marketed under the product name,
Emed-System,is a multiple component system capable
of sampling 150,000 sensors/sec. This number is the
ultimate determinant of resolution, size of active area,
and sampling rate of the device. Increasing resolution,
for example, necessitates reduced active platform area
and/or sampling rate. The Emed SF system (Novel,
Inc., Munich, Germany), currently marketed for the
objective assessment of dynamic foot pressure distri-
bution, has two sensors per cm2, an active measuring
area of 27.4 cm x 48.8 cm, and a collection rate of 70
images/sec. Each sensor has an individual calibration
curve, and accuracy of the displayed pressure values
is good. The multiple component nature of the system
allows use of platforms of variable size and resolution
158 ALEXANDER ET AL.
and the use of 2-mm thick flexible insole mats. These
mats provide a means of assessing the influence of
orthotics and shoewear on plantar foot pressures. Ex-
tensive software allows selection of specific regions for
pressure analysis and storage of these preselected
areas on computer for later utilization, an important
feature for use of the device in prospective studies.
The Critical Light Reflection Technique
The critical light reflection technique of assessing
plantar pressure distribution was originally described
by Chodera and Lord.'' The principles outlined by
Chodera and Lord'' were refined by Betts et
Duckworth et a1.2032' and Franks et al.23In a number of
publications, they outlined the use of their system and
detailed its components. The hardware consists of a
plastic sheet, a side illuminated transducer-mounted
glass plate, a video camera, and a microcomputer. The
plastic sheet is composed of an irregular deformable
surface with multiple tiny knobs which flatten against
the glass surface when pressure is applied. Firm con-
tact of the sheet to the glass surface disrupts the
internal reflection of light due to the high refracture
index of the plastic allowing light to scatter from the
point of contact (Fig. 4). The intensity of the light emitted
is related to the surface area of direct glass-plastic
apposition. As the load applied to the plastic mat in-
creases, individual contact spots increase to a maxi-
mum size and new spots are recruited. A linear rela-
tionship between pressure applied and the number of
spots of light per mm2and between the number of light
spots and image intensity was demonstrated. Thus,
the intensity of the reflected light correlated directly
with the pressure applied except at very low and high
pressure levels (not defined by the authors). Other
properties of the originally described mat demonstrated
Plastics
\ ll1111ll1
Total internal reflection Internal light scattering
at interface
Foot & Ankle/Vol. 11, No. 3/Decernber 1990
by the investigators included a high strain rate depend-
ence, a rapid image response to the application of
pressure (but a considerable lag in response to de-
creasing load), creep deformation of the mat with sus-
tained loads (applies more to static than dynamic stud-
ies), and marked temperature sensitivity of the mat with
a 10% to 15% error in pressure measurement with a
change in ambient temperature of 5OC.
Data processing in this system is by a microproces-
sor which is capable of capturing 25 frames/sec. Direct
digitization of the video image by the microprocessor
eliminates the need for video tape storage and facili-
tates data analysis. Spatial resolution with this device
is approximately 2 x 3 mm. Image intensity resolution
of 64 levels is possible but "iso-pressure" contour dis-
tributions break these down into manageable ranges
to make visual analysis simpler. A joy stick allows the
selection of specific areas for pressure analysis. For
each of the captured frames through the stance phase,
pressure in the specific area can be determined. A plot
of pressure versus time for each area allows assess-
ment of the length of time a high pressure is maintained
in a certain area (pressure time integral)-a factor that
may be more important than the simple peak pressures.
A similar system using critical light reflection, a mat
with a conical studded under-surface,and triaxial analy-
sis of applied force has been used by Chao et al.''
Polyurethane Photoelastic Plastic Sheet
Rhodes et have recently introduced the use of
a 20 X 15 in piece of polyurethane photoelastic plastic
as a transducer. The photoelastic characteristics of this
material causes variable rotation of the plane of polar-
ized light and when a circular polarizer is used in front
of the sheet it appears black when unstrained (i.e.,
unloaded). When loaded, the strained locations appear
Foot pressure
at interface
Foot & Ankle/Vol. 11, No. S/December 1990
lighter and the intensity of the emitted light is propor-
tional to the differences in the principle strains. Video
image of the sheet is fed into a computer which calcu-
lates a response for each 3 x 3 mm area. The data for
each area is stored, and as with most commercially
available systems can be displayed in a variety of ways.
The system is calibrated for each transducer used as
pressure response curves and maximum response var-
ies for each transducer, depending on the hardness of
the plastic. Although still in the development stages,
this system may be capable of providing fairly accurate
quantitative data at a reasonable cost.
Shear Sensitive Liquid Crystals
A unique method of assessing plantar pressure dis-
tribution was described by Scranton and McMasteF7
in 1976. Rather than using a deformable mat, these
authors used shear sensitive liquid crystals encased in
a flexible plastic sheet to assess plantar pressure dis-
tribution. Application of pressure to the sheet resulted
in a change in the color of the crystals from a light to a
dark blue in such a manner that a wave length response
was proportional to the shear forces applied. With this
special sheet lying on a piece of clear plastic, motion
picture recordings of the entire stance phase were
made. No attempt was made, however, to translate the
color wave length changes into absolute pressure
values.
Critical Comparison of Techniques
The only comparison of different techniques of plan-
tar pressure assessment in print is by Hughes et a(.“
These authors studied a group of normal subjects using
the Harris mat, the Dynapod (transducer matrix of
Hutton and Dhanendran2’) and the Pedobarograph(crit-
ical light reflection device as described by Duckworth
et aL2’ and Betts et al.’). Their emphasis was on the
comparison of the latter two devices. The Pedobaro-
graph was found to generate more reproducible results
and was more sensitive to lower loads; properties
attributable to the greater resolution of this device.
However, it lacked the accuracy and the rapid response
of the Dynapod. Under high loading conditions, slow
reaction of the Pedobarograph foil results in a low
reading for the absolute pressure in the specific area
of interest. The faster sampling rate and greater accu-
racy of the Dynapod account for its more realistic
estimation of forces under high load areas. These dis-
crepancies in the capabilitiesof the two devices become
most evident when looking at low lesser toe pressures
and high great toe, first metatarsal and second meta-
tarsal head pressures. The Dynapod consistently
underestimated the load taken by lesser toes, yet more
accurately reflected the high pressures under the great
CONTACT FORCES AND PRESSURE DISTRIBUTION 159
toe and the first and second metatarsal heads. These
results point out the need to take into account the
characteristics of the individual measuring devices
when evaluating results and when comparing data ob-
tained from two different devices.
PART II: CLINICAL APPLICATIONS OF DYNAMIC
FOOT-TO-GROUND PRESSURE ASSESSMENT
To facilitate consideration of the clinical applications
of the various techniques described, those studies pro-
viding data on a series of either normals or patients
with a specific diagnosis will be reviewed together and
their data integrated. The areas covered will include;
1. normal walking,
2. the effects of shoe wear and immobilization de-
vices,
3. running,
4. neuropathic and diabetic foot problems,
5. the rheumatoid foot, and
6. the effects of hallux valgus, first metatarsophalan-
geal silastic arthroplasty, heel pain, and talonavic-
ular and triple arthrodesis on dynamic foot pres-
sure.
Normal Walking
The studies of Grundy et al.,25Hutton and Dhanen-
dran,” Soame~,~’ Katoh et al.,3’ Cavanagh and Ae,13
and Chao et aI.,l5 have been most helpful in the as-
sessment of plantar distribution of forces in normal gait.
Study to study, the findings are relatively consistent
with a few notable exceptions. In barefoot walking, heel
strike is initially on the posterolateral aspect of the
heel,31and peak heel pressures are not reached until
approximately 25% of stance phase5’ at which point
the heel, lateral midfoot, and metatarsals are all making
contact with the ground. The velocity of center pressure
is very high in initial heel strike indicating rapid forward
transfer of f o r ~ e . ’The
~ velocity of center of pressure
decelerates initially after heel strike, but then acceler-
ates again to rapidly cross the midfoot.
Midfoot pressures are usually low. As weight is trans-
ferred from the hindfoot to the forefoot, the center of
pressure passes through the midfoot region, but at this
point represents an average of forefoot and hindfoot
forces rather than a true peak pressure in the midfoot
area.13 Total heel and midfoot contact time is approxi-
mately 50% of stance. Hutton and Dhanendran” found
increasing loads taken by the midfoot with increasing
age, implying a gradual collapse of the longitudinal arch
with greater longevity. Scranton and McMastep7
showed greater midfoot weight bearing in patients with
pes planus and less in those with a cavus foot.
160 ALEXANDER ET AL. Foot & Ankle/Vol. 1 1, No. 3/December 1990

The most interestingand variable weight-bearing pat-
terns, both in normal and diseased states, occur in the
forefoot. As early as 40% of stance, center of pressure
is located in the f ~ r e f o o t 'at
~ which point its velocity
markedly decelerates. The low velocity of the center of
pressure in the forefoot region is indicative of the sig-
nificant contribution of the metatarsal heads to weight
bearing25(Fig. 5). Peak pressures in the forefoot are
not reached until approximately 80% of stance phase.50
A comparison of forefoot to heel, foot to floor impulse,
a product of applied force and time of application,
indicates that the average load-bearing function of the
forefoot is approximately three times that of the heel in
the barefoot i n d i ~ i d u a l .The
~ ~ variation that Grundy
found in this ratio (from 2.0 to 5.05) is consistent with
the variety of weight-bearing patterns found in normals
by Chao et aI.l5 who grouped patients into heel, fore-
foot, and toe walkers and found that the majority of
patients were forefoot and toe walkers.
In the progression of normal stance phase, the center
of pressure finally migrates medially across the meta-
tarsal break and terminates in the region of the great
and second toe at push 0ff.25331The metatarsal heads
are in contact with the floor approximately 60% to 80%
of stance p h a ~ e . ' ~ Assessment
.~' of metatarsal head
pressure with pad transducers used by Soames5' found
that in barefoot walking the highest peak pressure and
greatest foot-floor impulse (pressure-time integral) was
under the third metatarsal head. This varies greatly
from the results of Hutton and Dhanendran,*' who with
a load cell matrix force plate found peak first metatarsal
head pressures three times that of the highest lesser
metatarsal head pressure in normal individuals. The
latter authors also showed great toe vertical reaction
pressure six times that of the highest value for the
lesser toes. Soames also found greater peak pressures
under the great toe but not near the magnitude of
difference from the little toes reported by Hutton and
Dhanend~an.~' This discrepancy is likely related to the
differences in measurement technique in these two
studies, floor-mounted versus foot-mounted trans-
ducers. As mentioned previously, the floor-mounted
transducer matrices tend to underestimate lesser toe
loads due to poor resolution.
Looking at the effects of walking speed, Chao et al.
found that increased walking speed tends to shift
weight from the forefoot to the hindfoot and great toe
and that total contact force is increa~ed.'~
Foot Containment and Plantar Pressures
The influence of shoe wear on the distribution of
pressure under the foot is considerable. Although floor-
mounted transducer matrices are capable of showing
changes in the pattern of weight bearing while wearing
shoes, best illustrated by the center of pressure as-
sessment, they cannot compare with in-shoe trans-
ducers for accuracy of information on forces acting on
the foot itself. The findings in normal subjects in shoes
walking over floor-mounted devices show a greater
velocity of the center of pressure in the and
a decrease in the forefoot impulse, related to the shorter
duration of weight bearing in this region.
The most extensive data on the influence of shoe
wear is from the work of Soames.'' He found that shoe
wear reduced peak heel apex pressure and produced
a more even distribution of load under the heel (Fig. 6).
Forefoot effects were remarkable. Weightbearing at the
metatarsal head level shifted from the central metatar-
sals barefoot, to the medial side of the forefoot in shoes,
with maximum pressures under the first and second
metatarsals (Fig. 7). In shoes, contact time of the toes
ranged from 60% to 85% of stance, a considerable

0 Vertical force
0 Longitudinal horizontal
.a i5n L force
A Center of pressure

-- -- I
- Fig. 5. Focus and center of pressure in bare-

I 5 10
X. cm
1 5 - - - 20 25 30 foot walking. Redrawn from Grundy et aLZ5and
used with permission.
5 -
E
0
i
10 -
From Grundy et al:
15 - J Bone Joint Surg, 1975
Foot & Ankle/Vol. 1 1, No. 3/December 1990 CONTACT FORCES AND PRESSURE DISTRIBUTION 161

Contact time
Barefoot/In shoes

" 1 2 3 4 5 1 2 3 4 5
Peak pressures Pressure-time integral
Barefoot/ln shoes BarefootAn shoes
10.0
2.0
7.5 1.6
Peak Pressure-
1.2
pressure, 5.0 time integral,
0.8
kPax 100 2.5 kPa.s x 100 o.4
0 0
1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5
Transducer position Light = female
From Soames: J Biomed Eng, 1985 Dark = male
Fig. 6. Transducer measured plantar pressures at hindfoot and midfoot during normal walking. Calculated from S o a m e ~ . ~ '

Contact time-metatarsal heads

Barefootlln shoes
1001 . .

Contact 75
time, 50
?4 25
3'

6 7 8 9 1 0 6 7 8 910
Peak pressures Pressure-time integral

r een
pressure, 5.0
kPax 100 2.5
0
6 7 8 9106 7 8 910 6 7 8 9 1 0 6 7 8 910
Transducer position Light = female
From Soames: J Biomed Eng, 1985 Dark = male
Fig. 7. Transducer measured plantar pressures at forefoot during normal walking. Calculated from S o a m e ~ . ~ '
162 ALEXANDER ET AL.
increase from 50% to 55% of stance for barefoot
walking. Peak pressures under the toes in shoes were
generally higher as well (Fig. 8). The resulting higher
foot-floor impulse under the toes in shoes was associ-
ated with reduced weight transfer by the metatarsal
heads. A tendency for high-heeled shoes to load the
medial metatarsals and to unload the lateral metatarsals
was also demonstrated by Soames. He made no com-
ment, however, on the relative foot-floor impulse of the
hindfoot and forefoot in high-heeled shoes. Both Katoh
et aL3' and Grundy et al.,25 using conventional force
plates and center of pressure determinations, found a
dramatic tendency for high-heeled shoes to reduce
forefoot impulse and shift weight bearing to the midfoot
and hindfoot.
Shear transducers used by Pollard et al.,42have given
additional information on forces acting on the foot in
shoe wear. Longitudinal and transverse shear as well
as vertical forces were measured under the hallux, the
metatarsal heads, and the heel (Fig. 9). Maximal longi-
tudinal shear occurs under the metatarsal heads. Lat-
erally directed transverse shear is maximal under the
central metatarsal heads, and present to a lesser extent
under the hallux. The heel pad is subjected to a small
medial shear force. A study of a variety of foot wear
and immobilizing devices, showed that a plaster of paris
cast was the most effective means of reducing peak
values for shear and vertical force components. Re-
cordings for leather and rubber-soled shoes were es-
sentially identical. Leather shoes with low density plas-
3'
Peak pressures
Barefoot/ln shoes
O.O
7.5
1
1 1.6
Peak I Pressure-
pressure, 5.0
kPax 100 2.5
0 0
11 12 13 14 15 11 12 13 14 15
Transducer position
From Soames: J Biomed Eng, 1985
Fig. 8. Transducer measured plantar pressures at toes during normal walking. Calculated from S ~ a m e s . ~ ~
Foot & Ankle/Vol. 1 1 , No. S/December 1990
tazote inserts and a special surgical shoe with double
layer inserts equally reduced shear and vertical forces.
A rockerbottom sole was found to reduce longitudinal
shear, but had no effect on vertical forces or transverse
shear when compared with a regular shoe. Barefoot
walkers demonstrated much higher soft tissue shear
forces than individuals in shoes.
Methods of immobilization commonly used following
foot surgery have been studied by Shereff et aL4' With
transducers located under the first and third metatarsal
heads and the heel, short leg, ankle, and slipper casts
with either a rocker or a posterior heel, or one of a
variety of cast shoes were compared (Fig. 10). Wooden
postoperative shoes were also investigated. First and
third metatarsal head regional vertical peak pressures
were most effectively reduced by casts with a poste-
riorly placed heel. With reference to cast heights (short
leg versus ankle versus slipper) the lower the cast, the
lower the plantar vertical forces on all three trans-
ducers. The differences however, are not large and the
authors suggest that patient comfort should dictate the
cast height chosen. The postoperative wooden shoe
generated the greatest peak forefoot pressures, a fac-
tor certainly worth considering in clinical practice.
Foot Pressure in Running
Extensive investigation of runners has been carried
out by Cavanagh and his associates. In his publication
with Lafortune using a Kistler force plate, Cavanagh
and Lafort~ne'~found that running patterns varied con-
Contact time of toes
Barefoot/ln shoes
1001
~~
Contact 75
time, 50
96 25
11 12 13 14 15 11 12 13 14 15
Pressure-time integral
Barefoot/ln shoes
1.2
time integral,
0.8
kPa.s x 100 o.4
11 12 13 14 15 11 12 13 14 15
Light = female
Dark = male
Foot & Ankle/Vol. 1 1, No. S/December 1990 CONTACT FORCES AND PRESSURE DlSTRlSUTlON 163

Longitudinal shear Transverse shear

120
0 Extradepth with

with insoles
Rockersoles

20
Fig. 9. Shear forces under the

:I-
L
foot: influence of shoewear. Modi-
fied from Pollard et
0
C

e
Q) -6l)
a - 100
Hallux 1 2/3 4 5 Heel Hallux 1 2/3 4 5 Heel
Metatarsals A L Metatarsals A
Transducer positions
From Pollard el al: J Biomed Eng, 1983

Percentage of barefoot pressure

0 20 40 60 80 100
I I 1 I 1 1
Wooden shoe
Short-leg walking cast
Posterior heel
Rocker heel
Rocker shoe
Ankle cast
Posterior heel
Rocker heel
Rocker shoe
Slipper cast
0 First metatarsal head

With shoe
a Third metatarsal head

Adapted from Shereff et al: CORR, 1979

Fig. 10. Vertical forces under first and third metatarsal heads with different types of postoperative regimens. Adapted from Shereff et al."

siderably from one distance runner to the next. Two
patterns of initial foot-to-ground contact were ob-
served. Although first contact occurs almost invariably
along the lateral border of the foot, the center of pres-
sure at impact was found to be either in the hindfoot or
midfoot area (Fig. 11). Midfoot strikers at initial ground
contact land with a relatively flat foot more evenly
distributing the force over the bottom of the shoe.
Those individuals showed a smoother transition from
braking to push off. Cavanagh and LaFortune also
found that some subjects were capable of running at
the same speed as others but exerted 30% lower peak
vertical ground reaction force values. This difference in
peak pressure did not correlate with the point of first
impact, rear foot versus midfoot. Also interesting was
that braking is still occurring when the center of pres-
sure reached 70% of the length of the shoe from the
heel. The center of pressure is from 60% to 80% of the
length of the shoe in both groups for most of contact
time. Pressure distribution in barefoot runners has also
been studied by Cavanagh using a 1000 element array
of 5 x 5 mm capacitance transducers.'* He found a
rapid transfer of weight to the medial heel after lateral
heel strike and a concentration of forefoot pressure
under the first and second metatarsal heads. In bare-
foot runners the lesser toes contributed minimally to
164 ALEXANDER ET AL.
Rearfoot Strikers
Rear Mid Fore Rear
From Cavanaugh and LaFottune: J Biomech, 1980
push off. Cavanagh does not hesitate to point out that
plantar pressure distribution is likely much different
running in shoes which distribute weightbearing more
widely and greatly reduce peak pressures.
The Diabetic and Neuropathic Foot
The most extensive clinical application of devices for
the assessment of plantar pressure distribution has
been to evaluate the diabetic and neuropathic foot.
Stokes et al.,54Duckworth et a1.,2' Ctercteko et aI.,l7
Bauman et a1.,6 and Boulton et a1.I' have investigated
this patient population. Their findings are as follows: (1)
dynamic pressure distribution measurements show
high risk pressure areas more effectively than static
pressure measurements;21(2) areas of ulceration cor-
relate well with areas of maximal vertical and shear
forces,42both in patients with healed ulcers2' and in
those with active ulcers;54(3) progression of neuro-
pathic changes is associated with increasing abnor-
mality of foot loading; (4) with neuropathy, weight bear-
ing shifts from the medial to the lateral border of the
forefo~t;~' (5) load taken by the toes is reduced, likely
a consequence of intrinsic denervati~n;'~ (6) reduced
weightbearing by the toes results in greater metatarsal
head level impulse and peak pressure^'^ (Ctercteko
hypothesizes that plantar ulceration in diabetics is most
frequently under the first metatarsal head as in the
normal foot 70% of toe loading is through the great
toe, and with intrinsic denervation this is transferred to
the first metatarsal head area); and (7) partial foot
amputations reduce the total load-bearing area, in-
creasing local peak pressures and requiring careful
attention to protection by effective load distribution.
Following ray amputation the risk of ulceration under
the remaining adjacent metatarsals is particularly
high.54
The neuropathic foot of the leper was a major focus
of Bauman et a1.,I6 who used transducers strapped to
Foot & Ankle/Vol. 11, No. 3/December 1990
Midfoot Strikers
Fig. 11. Vertical forces in distance
runners and variable center of pres-
sure path From Cavanagh and La-
fortune l4 Used with permission of
Pergamon Press
Mid Fore
the bottom of the foot to study the effects of neuro-
pathic insensitivity, neuropathic deformity, and modify-
ing shoe wear on plantar pressures. Total contact force
under the anesthetic foot was found not to be in-
creased. Foot drop, with an unapposed tibialis poste-
rior, was associated with increased lateral loading and
potential for ulceration of the lateral forefoot. High peak
pressures under the metatarsal heads were seen with
metatarsophalangeal joint extension secondary to in-
trinsic denervation. All deformed feet had one or two
areas of focal force concentration. The studies of Bau-
man et a1.,6 further reinforced the importance of plantar
load redistribution and demonstrated the effectiveness
of arch supports, metatarsal bars, and rocker bottoms
placed near the center of the foot in reducing load
concentration.
Rheumatoid Foot
The rheumatoid foot is another area of particular
interest. Work in this area has been performed by
Sharma et al.,48 using the floor mounted matrix of
Hutton and Dhanendran and by Minns and Craxford3*
using a pressure sensitive sandal. Pattern changes
found were very similar to those of diabetics. Toe
loading was reduced and there was a general tendency
to increase loading of the lateral metatarsal heads. This
lateral shift could not be explained by the authors.
The Great Toe
Conditions affecting the great toe have also been the
subject of studies. In hallux valgus, decreased weight-
bearing by the first and second toes along with in-
creased weight transfer through the lateral metatarsals
has consistently been ~ b s e r v e d .In~~one
, ~ investiga-
~
tion, patients studied preoperatively were also studied
following a Keller resection arthroplasty. This operation,
which shortens and realigns the great toe, further re-
duces weight bearing by the hallux and increases load-
Foot & Ankle/Vol. 11, No. S/Decernber 1990
ing on the first metatarsal head.*’ Beverly et al.,’ dem-
onstrated in patients with silastic implant arthroplasty
of the first metatarsophalangealjoint, a 43% decrease
in hallux peak loads on the operated versus the unop-
erated side and a 65% increase in peak loads under
the second and third metatarsal heads. Operative indi-
cation for the silastic implant made a difference. Stokes
et al., found that those patients having a silastic implant
for hallux rigidus showed normal loads taken by the
hallux, whereas using the implant for hallux valgus was
ineffective in improving great toe weight
Using a force plate to determine center of pressure,
Merkel et found that after Mitchell osteotomy
patients avoided great toe weight bearing with push off
occurring from the first metatarsal head region or the
extreme lateral forefoot. Feet with short first metatar-
sals showed a tendency for lateral deviation of the
center of pressure in the terminal phases of
In our own, as yet unpublished, study’ of patients
with first metatarsophalangeal arthrodesis for hallux
rigidus, an inverse relationship was found between the
angle of inclination (to the floor) of the proximal phalanx
of the great toe following fusion and great toe contact
time, total vertical force at maximum great toe contact,
aft shear force at maximum great toe contact, and the
ratio of the impulse under the great toe to that under
the first metatarsal head.’ Weight-bearing function of
the great toe was clearly related to the angle at which
the toe was fused. In light of investigations mentioned
earlier, lower metatarsal head pressures and a reduc-
tion in the incidence of postoperative metatarsalgia
would likely follow fusion of the hallux in the position of
optimal function.
Heel Pain and Hindfoot Arthrodesis
The influence of conditions of the hindfoot on foot
pressure distribution have also been investigated. Hind-
foot arthrodeses, both isolated talona~icular~’ and triple
a r t h r o d e s i ~ cause
, ~ ~ a greater contact force at heel
strike, a phenomenon possibly related to the loss of
normal impact absorbing varus to valgus roll of the heel
in the early phase of stance.
Katoh et al. have studied weight-bearing patterns in
patients with heel pain These investigators
subdivided patients with this syndrome into two groups:
(1) plantar fasciitis with tenderness extending along the
plantar fascia and heel pain aggravated by toe exten-
sion, and (2) painful heel pad characterized by local
heel tenderness with no demonstrable cause of heel
pain. Center of pressure and ground reaction force
analysis showed a significant reduction of heel impulse
(force x time integral) in the painful heel pad group with
a statistically significant increase in midfoot impulse. In
the plantar fasciitis group, however, the midfoot and
CONTACT FORCES AND PRESSURE DISTRIBUTION 165
forefoot show statistically significant increases and de-
creases, respectively. In these individuals,the decrease
in hindfoot impulse was not significant. The reduction
in forefoot impulse indicated an avoidance of toe dor-
siflexion in patients with plantar fasciitis.
CONCLUSIONS
Multiple devices have been used to assess foot-to-
ground contact forces and plantar pressure distribution.
Technique selection, in some cases, is dependent on
the clinical problem to be studied. With minimal time
required for patient preparation, floor-mounted trans-
ducer matrices and foil-covered translucent force plat-
forms provide useful information about time dependent
pressure distribution and high load areas. Although
these types of studies are helpful in planning pedorthic
and surgical intervention, they do not evaluate the
effectiveness of orthotics and shoe wear in the reduc-
tion of both vertical and shear forces. In-shoe trans-
ducers provide this information, but reproducibly instru-
menting the patient for this type of evaluation requires
time consuming attention to detail. There is a place in
the research setting for both floor-mounted and in-shoe
devices. The quantitative accuracy and resolution of
these tools will likely improve as research in this area
keeps pace with advancing technology.
For the practicing clinician, the Harris mat provides
an excellent economical means of qualitatively evalu-
ating plantar pressure distribution. The presence, how-
ever, of computer hardware in the office of most or-
thopedic groups, together with the availability of inex-
pensive, good quality video equipment and gray scale
software will eventually make the critical light reflection
foil technique without transducers or the photoelastic
sheet method reasonably affordable qualitative tools.
The value of this type of device as an investigative tool
in the office setting will depend on the results of exten-
sive prospective clinical studies which, to date, have
not been performed.
Some of the devices described in this publication as
well as those that will be developed in the future as
technology advances, will provide the objective docu-
mentation necessary to validate prospective studies of
patients with a variety of foot ailments. Evidence from
these prospective studies supporting or refuting the
efficacy of currently used therapeutic techniques should
improve the overall care of patients with foot and ankle
problems.
REFERENCES
1. Alexander, I.J., Chao, E.Y.S., Bleimeyer, R.R., Morrey, B.F.,
and Johnson, K.A.: Great toe function following first metatar-
sophalangeal arthrodesis (unpublished data).
166 ALEXANDER ET AL.
2. Arcan, M., and Brull, M. A.: A fundamental characteristic of the
human body and foot, the foot-ground pressure pattern. J.
Biomech., 9:453-457, 1976.
3. Barnett, C.H.: A plastic pedograph. Lancet, 2:273, 1954.
4. Barnett, C.H.: The phases of human gait. Lancet, 2:617-621,
1956.
5. Bauman, J.H., and Brand, P.W.: Measurement of pressure
between foot and shoe. Lancet, 1:629-632,1963.
6. Bauman, J.H., Girling, J.P., and Brand, P.W.: Plantar pressures
and trophic ulceration: an evaluation of footwear. J. Bone Joint
Surg., 45B652-673, 1963.
7. Betts, R.P., Duckworth, T., Austin, I.G., Crocker, S.P., and
Moore, S.: Critical light reflection at a plastic/glass interface and
its application to foot pressure measurements. J. Med. Eng.
Technol., 4:136-142, 1980.
8. Betts, R.P., Franks, C. I., Duckworth, T., and Burke, J.: Static
and dynamic foot-pressure measurements in clinical orthopaed-
ics. Med. Biol. Eng. Comput., 18:674-684, 1980.
9. Beverly, M.C., Horan, F.T., and Hutton, W.C.: Load cell analysis
following silastic arthroplasty of the hallux. Int. Orthop., 9:lOl-
104,1985.
10. Boulton,A.J.M., Hardisty, C.A., Betts, R.P., Franks, C.I., Worth,
R.C., Ward, J.D., and Duckworth, T.: Dynamic foot pressure
and other studies as diagnostic and management aids in diabetic
neuropathy. Diabetes Care, 6:26-33, 1983.
11. Carlet, G.: Sur la locomotion humaine. Ann. Sci. Naturelles,Serie
5:1-92, 1872.
12. Cavanagh, P.R.: The biomechanics of lower extremity action in
distance running. Foot Ankle, 7:197-217, 1987.
13. Cavanagh, P.R., and Ae, M.: A technique for the display of
pressure distribution beneath the foot. J. Biomech., 13:69-75,
1980.
14. Cavanagh, P.R., and Lafortune, M.A.: Ground reaction forces
in distance running. J. Biomech., 13:397-406, 1980.
15. Chao, E.Y., Spiegl, P.V., Cass, J.R., Bleimeyer, R.R., and
Cahill, B.P.: Foot-to-groundpressure/force measurement in nor-
mal subjects at varying walking speeds (unpublisheddata).
16. Chodera, J.D., and Lord, M.: Pedobarographic foot pressure
measurement and the applications. In Disability. Kenedi, R.M.,
Paul, J.P., and Hughes,J. (eds.), London, MacMillan Press, 1979,
pp. 173-181.
17. Ctercteko, G.C., Dhanendran, M., Hutton, W.C., and Le
Quesne, L.P.: Vertical forces acting on the feet of diabetic
patients with neuropathic ulceration. Br. J. Surg., 68:608-614,
1981.
18. Dall, G.: Dynamic assessment of the load distribution on the
plantar surface of the foot using the University of Cape Town
walkway and its clinical application. Foot Ankle, 4286-291,
1984.
19. Draganich, L.F., Andriacchi, T.P., Strongwater, A.M., and Gal-
ante, J.O.: Electronic measurement of instantaneous foot-floor
contact patterns during gait. J. Biomech., 13:875-880, 1980.
20. Duckworth, T., Betts, R.P., Franks, C.I., and Burke, J.: The
measurement of pressure under the foot. Foot Ankle, 3:130-
141, 1982.
21. Duckworth, T., Boulton, A.J.M., Betts, R.P., Franks, C.I., and
Ward, J.D.: Plantar pressure measurements and the prevention
of ulceration in the diabetic foot. J. Bone Joint Surg., 678379-
85, 1985.
22. Elftman, H.: A cinematic study of the distribution of pressure in
the human foot. Anat. Rec., 59:481-491, 1934.
23. Franks, C.I., Betts, R.P., and Duckworth, T.: Microprocessor-
based image processing system for dynamic foot pressure stud-
ies. Med. Biol. Eng. Comput., 21566-572, 1983.
Foot & Ankle/Vol. 11, No. 3/December 1990
24. Frost, R.B., and Cass, C.A.: A load cell and sole assembly for
dynamic pointwise vertical force measurement in walking. Eng.
Med., 10:45-50, 1981.
25. Grundy, M., Blackburn, P.A., Tosh, P.A., McLeish, R.D., and
Smidt, L.: An investigation of the centres of pressure under the
foot while walking. J. Bone Joint Surg., 57B98-103, 1975.
26. Hennacy, R.A., and Gunther, R.: A piezoelectriccrystal method
for measuring static and dynamic pressure distributions in the
feet. J. Am. Podiatr. Med. Assoc., 65444-449, 1975.
27. Hennig, E.M., and Nicol, K.: Registration methods for time-
dependent pressure distribution measurements with mats work-
ing as capacitors. Int. S. Biomech., 2A361-367, 1978.
28. Hughes, J., Kriss, S., and Klenerman, L.: A clinician's view of
foot pressure: a comparison of three different methods of meas-
urement. Foot Ankle, 7:277-284, 1987.
29. Hutton, W.C., and Dhanendran, M.: The mechanics of normal
and hallux valgus feet-a quantitative study. Clin. Orthop.
157:7-13,1981,
30. Hutton, W.C., and Drabble, G.E.: An apparatus to give the
distribution of vertical load under the foot. Rheumatoid Phys.
Med., 11:313-317, 1972.
31. Katoh, Y., Chao, E.Y.S., Laughman, R.K., Schneider, E., and
Morrey, B.F.: Biomechanical analysis of foot function during gait
and clinical applications. Clin. Orthop., 177:23-33, 1983.
32. Katoh, Y., Chao, E.Y.S., Morrey, B.F., and Laughman, R.K.:
Objective technique for evaluating painful heel syndrome and its
treatment. Foot Ankle, 3:227-237, 1983.
33. Lereim, P., and Serck-Hanssen, F.: A method of recording
pressure distribution under the sole of the foot. Bull. Prosthet.
Res., 20:118-125, 1973.
34. Lord, M.: Foot pressure measurement: a review of methodology.
J. Biomed. Eng., 3:91-99, 1981.
35. Manley, M.T., and Solomon, E.: The clinical assessment of the
normal and abnormal foot during locomotion. Prosthet. Orthot.
Int., 3103-110, 1979.
36. Marey, M.: De la locomotion terrestre chez les bipedes et les
quadrupedes. J. de I'Anat. et de la Physiol., 9:42, 1873.
37. Merkel, K.D., Katoh, Y., Johnson, E.W., Jr., and Chao, E.Y.S.:
Mitchell osteotomy for hallux valgus: long-term follow-up and
gait analysis. Foot Ankle, 3189-196, 1983.
38. Minns, R.J., and Craxford, A.D.: Pressure under the forefoot in
rheumatoid arthritis: a comparison of static and dynamic meth-
ods of assessment. Clin. Orthop., 187:235-242, 1984.
39. Miyazaki, S., and Ishida, A.: Capacitive transducer for continu-
ous measurement of vertical foot force. Med. Biol. Eng. Comput.,
22:309-316, 1984.
40. Miyazaki, S., and Iwakura, H.: Foot-force measuring device for
clinical assessment of pathologicalgait. Med. Biol. Eng. Comput.,
16~429-436,1978.
41. Nicol, K., and Hennig, E.M.: Measurement of pressure distribu-
tion by means of a flexible, large-surfacemat. Int. S. Biomech.,
2A:374-380, 1978.
42. Pollard, J.P., Le Quesne, L.P., and Tappin, J.W.: Forces under
the foot. J. Biomed. Eng., 537-40, 1983.
43. Ranu, H.S.: Miniature load cells for the measurement of foot-
ground reaction forces and centre of foot pressure during gait.
J. Biomed. Eng., 8:175-177, 1986.
44. Rhodes, A., Sherk, H.H., Black, J., and Margulies, C.: High
resolution analysis of ground foot reaction forces. Foot Ankle,
9:135-138, Dec. 1988.
45. Schwartz, R.P., and Heath, A.L.: Some factors which influence
the balance of the foot in walking: the stance phase of gait. J.
Bone Joint Surg., 19:431-442, 1937.
Foot & Ankle/Vol. 1 1, No. 3/December 1990 CONTACT FORCES AND PRESSURE DISTRIBUTION 167

46. Schwartz, R.P., and Heath, A.L.: The definition of human loco-
motion on the basis of measurement: with description of oscil-
lographic method. J. Bone Joint Surg., 29:203-214, 1947.
47. Scranton, P.E., Jr., and McMaster, J.H.: Momentarydistribution
of forces under the foot. J. Biomech., 9:45-48, 1976.
48. Sharma, M., Dhanendran, M., Hutton, W.C., and Corbett, M.:
Changes in load bearing in the rheumatoid foot. Ann. Rheum.
Dis., 38549-552, 1979.
49. Shereff, M.J., Bregrnan, A.M., and Kurnmer, F.J.: The effect of
immobolizationdevices on the load distribution under the foot.
Clin. Orthop., 192:260-267, 1985.
50. Soames, R.W.: Foot pressure patterns during gait. J. Biomed.
Eng., 7:120-126, 1985.
51. Soarnes, R.W., Blake, C.D., Stott, J.R.R., Goodbody, A., and
Brewerton, D.A.: Measurement of pressureunder the foot during
function. Med. Biol. Eng. Comput., 20:489-495, 1982.
52. Spolek, G.A., and Lippert, F.G.: An instrumented shoe-a
portable force measuringdevice. J. Biomech., 9:779-783,1976.
53. Stein, H., Sirnkin, A., and Keenan, J.: The foot-ground pressure
distribution following triple arthrodesis. Arch. Orthop. Trauma.
Surg., 98:263-269, 1981.
54. Stokes, I.A.F., Faris, I.B., and Hutton, W.C.: The neuropathic
ulcer and loads on the foot in diabetic patients. Acta. Orthop.
Scand., 46:839-847, 1975.
55. Stokes, I.A.F., Hutton, W.C., Stott, J.R.R., and Lowe, L.W.:
Forces under the hallux valgus foot before and after surgery.
Clin. Orthop., 142:64-72, 1979.

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