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The Study of Plantar Pressure Distribution in Normal and

Pathological Foot

Article in Polish Journal of Medical Physics And Engineering · January 2006

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Pol J Med Phys Eng 2006;12(1):25-34
PL ISSN 1425-4689

D.V. Rai, L.M. Aggarwal

The Study of Plantar Pressure Distribution

in Normal and Pathological Foot

Department of Biophysics, Panjab University, Chandigarh–160014, India

e-mail: [email protected]

The distribution and magnitudes of plantar pressure have been measured to identify the
functional manifestations of foot disorders. Pedobarograph measurements of normal and abnormal
foot were monitored during walking using computer assisted optical pedobarograph. Results
showed that the peak pressures and their duration varied significantly in normal and pathological
subjects. Peak pressures were also correlated with pathological conditions. The percentage contact
time of heel, forefoot and toe was 59±10, 79±13, 68±20 and 39±29, 76±22, 45±43 in normal and
pathological foot respectively. It was found that dynamic plantar pressure provides important
information about the human gait. The data could be useful in understanding the variations in
walking and orthopaedic disorders related to foot.
Key words: plantar pressure, pedobarograph, gait, stance phase, contact time.

Introduction
In the recent years, the plantar pressure has widely been accepted as a vital
biomechanical parameter to evaluate human walking. The distribution and magnitude
of plantar pressure can provide useful information to diagnose the various foot
disorders. Plantar pressure measurements during standing, walking or other activities
can demonstrate the pathomechanics of the abnormal foot and yield objective measures
to track disease progression [10]. A callus formation on the plantar surface of the foot
can elevate the plantar pressure up to 30% [30]. Bony abnormalities that are observable
on radiological examination may offer the possibility of predicting some of the variance
26 D.V. Rai et al.

in plantar pressure on the basis of structural factors alone [2, 26]. Several studies [3, 6,
10] on foot biomechanics have reported that plantar pressure variations is useful to
determine the abnormal gait. Pathologic gait can be broadly divided on the basic
etiology, into either neuromuscular or muscloskeletal [16]. Many research groups
realized the potential of pressure measurement technology for the diagnosis and
treatment of various foot disorders [1, 19]. Plantar pressure studies on the rheumatoid
foot have also been undertaken by a number of research groups [28, 11, 29].
Plantar pressure studies in patients with diabetic neuropathy have indicated a
relationship between excessive localized pressure and ulceration [3]. These patients are
at risk of recurrent ulceration and impaired pain because of increased pressures under
the metatarsal heads. Earlier studies [3, 17] have described the value of plantar pressure
analysis for the understanding of diabetic foot function as well as of the possibilities for
therapeutic intervention. Researchers have investigated therapeutic footwear for the
diabetic foot, especially various designs of rocker bottom shoes [22]. Numerous studies
have proven the usefulness of pressure distribution measurements for the prescription
of therapeutic footwear [5].
The damage to tissue in the foot not only depends upon the peak pressure, but it has
a great dependence on the type of physical activities carried out and the type of footwear
used. The effect of variation of the foot pressure measured with different gait parameters
is not fully understood. Therefore, there is a need to study normal and pathological
subjects to know the exact values of peak pressures on the plantar surface of the foot.
There is a wide variation of the threshold described by earlier researchers, which could
vary from 500 kPa to 1000 kPa [1, 3]. This seems to be more confusing and may lead to
incorrect interpretation of clinical observations. The diversity of commercially available
systems to measure the plantar pressure has resultatesd in different measuring systems
producing different results No proven pressure threshold for tissue damage exists, which
could be true for all systems [18]. Therefore, we used the technique of percentage
pressure normalized to peak pressure instead of absolute value of pressure.
In this study, plantar pressure distributions in normal as well as in pathological
subjects were evaluated. Peak pressure and its duration in the stance phase of the gait
were studied and any abnormality in the peak pressures was correlated with the
pathological situation. Dynamic pedobarographs obtained with an optical
pedobarograph were divided in the frames from heel to toe to calculate percentage time
period of contact.
The study of plantar pressure… 27

Material and Methods

Barefoot pressure measurements were carried out on 66 subjects (46 males and 20
females). Height and weight of all subjects were recorded. Fifty eight subjects who
participated in the study had normal gait and 8 had pathological gait. Subjects were in
the age group of 11 to 59 years (mean age 29±13 years). Normal subjects included in the
present study had no major musculoskeletal or neurological pathologies that affected
their gait. Figure 1 shows the schematic diagram of the complete experimental set up
used in the plantar pressure measurement which consists of an originally designed
optical pedobarograph, CCD camera, computer with Asha 3D software and printer.

Figure 1. Schematic diagram of Computerized Optical Pedobarograph

Prior to pressure measurements, subjects familiarized themselves with the testing

procedure. The subjects were invited to walk at a normal pace along a walkway. They
were asked to look straight ahead while walking over the foot pressure system. It was also
a problem whether the subject should be studied in the middle of a longer walk or during
the first step from rest. Data collection in mid gait was preferred as this gives correct
information of pressure distribution during normal walking. Pressure measurements
were made in the second step after the subject hit the top surface of the optical
pedobarograph. Before taking a final set of readings, it was ensured that the subjects
walked comfortably on the platform. From a fixed starting point, all the subjects were
asked to walk at their own pace. In order to reduce the error due to posture sway, three
readings for every individual subject were taken.
28 D.V. Rai et al.

Dynamic pedobarographs of all the subjects were recorded using a CCD camera
(National Panasonic M9500). For data analysis, the video recording obtained from the
optical pedobarograph of both feet of every individual was separated for the right and left
foot. This recording of the right and left foot was divided into frames using Jas®
Animation Shop™ version 3.0 software. All the frames were transported to the ASHA 3D
software developed during this study for plantar pressure measurements. The images
obtained by the optical pedobarograph were evaluated using this software. The software
maps the entire foot images and calculates the value of intensities for every pixel. The
pressure changes were recorded in the form of percentage intensity pattern. The analysis
of data began with a sequence of distribution showing the evolution of the load bearing
on the foot throughout the contact phase. This enabled any unusual features of foot
from heel to toe in a stance phase. The most useful information for the interpretation of
the clinical analysis was the peak pressure plots. The highest pressure, in terms of a
percentage intensity, in each part of the foot that occurred during any point of contact
during walking was recorded in relation to the maximum pressure.

Results
The total pressure distribution was relatively consistent in all the normal subjects. In
normal barefoot walking, the heel was the first portion of the foot to receive body weight
followed by midfoot and forefoot, finally the load shifted to the toe for lift off. In normal
subjects, the heel struck the ground on the posterolateral part of the heel, and the
maximum peak pressure occurred at approximately 18 to 36% of the stance phase where
the heel, midfoot and forefoot were in contact with the ground. The percentage average
contact time of the heel was 59±10 of the stance phase (Table 1).

Table 1. Percentage contact time in normal and pathological subjects

Normal Subjects Pathological Subjects

Heel 59±10 39±29

Forefoot 79±13 76±22

Toe 68±20 45±43

The study of plantar pressure… 29

Figure 2. Plantar pressure distribution and time period (percentage) in normal foot during
stance phase of gait from heel strike to toe off

The fifth metatarsal region accepted the load prior to the first metatarsal region. The
maximum peak pressure of the forefoot was observed during 70 to 82% of the stance
phase. The highest mean pressure in normal subjects, found under the second
metatarsal head, changed in such a way that that there was a gradual increase in peak
pressure from the fifth to the 2nd metatarsal followed by a decreased pressure under the
first metatarsal head. The toe region began to bear load prior to heel off and achieved a
very late peak during 80-91% of the stance phase. Figure 2 shows the plantar pressure
distribution in normal subjects from heel strike to toe off. It was also observed that the
center of the pressure varied from one person to another. In 88% of normal subjects, it
was found that maximum peak pressure was in the 2nd and 3rd metatarsal region. No
definite roll over process from heel to toes was observed in pathological subjects. The
heel pressure in pathological subjects was lower than in normal subjects. Figure 3 shows
30 D.V. Rai et al.

Figure 3. Plantar pressure distribution and time period (percentage) in pathologial foot
during stance phase of gait from heel strike to toe off

the pressure distribution in pathological subject having callus in the heel and forefoot. In
all the pathological subjects the average heel, forefoot and toe contact time was 39±29,
76±22 and 45±13, respectively (Table 1).

Discussion
The maximum peak pressure in the heel during 18-36% of stance phase supports the fact
that the center of pressure (COP) in normal walking starts from the heel. Then gradually
the COP moves from the heel to the toe through the midfoot and metatarsal regions.
Some of the investigators studying barefoot walking found that maximum peak
pressures developed under the metatarsals region evenly [23, 27], and others found it to
be unevenly distributed [25, 12]. Some earlier researchers have also suggested
The study of plantar pressure… 31

maximum pressure under the third metatarsal [13, 21]. Others have suggested
maximum pressure under the 1st metatarsal head [24, 20, 10]. Some suggested
maximum pressure under the second metatarsal head [6, 14, 7], whereas a few
researchers observed it under the hallux region [14]. The results obtained in this study
demonstrated that for most subjects the normal forefoot pressure patterns are highest
under the 2nd and 3rd metatarsal region and this was in agreement with the earlier
studies [4, 21]. Similar observations have been reported by Hughes et al [13, 15].
However, the percentage of normal subjects showing such results in their studies was
smaller. High pressure under the 2nd and 3rd metatarsal region provides valuable
information in assessing the pathological forefoot. In this study, it was also observed
that the variations in peak pressure and their time relationships occurred within fairly
narrow limits and in few cases skewed towards the upper limits, indicating that some
feet although symptomless, may in fact be pathological. Forty percent of all the subjects
demonstrated premature metatarsal termination, suggesting that the toes do not play a
significant role in transferring load. These results are in agreement with those reported
by Grundy et al [8].
In the pathological group, the plantar pressure distribution was entirely different
than that in normal subjects. The pressure distribution was in correlation with the type
and location of foot disorder. No definite roll over process like that in normal subjects
from heel to toes was observed in pathological subjects. Plantar pressure distribution in
the subject having callus in the heel and forefoot in the left foot had a different pressure
distribution than the right foot. The callus in the forefoot region was clearly visible;
however, pressure distribution indicated some pathology in the heel area, as the subject
was not able to bear any pressure in this region (Figure 3). On investigation, it was found
that the subject also had a small callus in the heal region. The maximum peak pressure
was observed in the midfoot. While striking the platform and lift off, very little or no
pressure was applied to the heel and forefoot. The contact time of the midfoot was 75%,
i.e. it was much higher than in normal subjects. The maximum peak pressure and the
contact time of the heel was nil (0.0%), indicating some pathology in the heel.

Conclusion
It may be concluded that dynamic plantar pressure is an important parameter which
provides information about the human gait. The technique of percentage pressure
32 D.V. Rai et al.

normalized to peak pressure was found to be quite useful in distinguishing normal and
pathological subjects. It helps in the correct interpretation of clinical observations using
pressure profiles normalized to the peak pressure. Normal subjects follow a set pattern of
roll over of the center of pressure from the heel to toe. Any change in this pattern could
help in detecting the pathology related to an orthopedic disorder. If applied clinically, in
routine for foot screening, the above technique could be an effective biomechanical tool
to diagnose various disorders related to the foot.

Acknowledgement
Authors are thankful to Prof Raj Bahadur, Head of the Department of Orthopedics, Govt
Medical College & Hospital, Chandiagrh (India) for his help, suggestions and
encouragement in carrying out this work.

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